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.UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


G     000  005  542     6 


NERVOUS    DISEASES. 

DANA. 


Fig.  210.— Composite  Photograph  SHowi.sf;  I;i:i,ati(ivs  ok  Cranial 
Fissures  and  Convolutions  (Alec  Fra.ser). 


UIIFACi:   'JO    THE 


TEXT-BOOK 


NERVOUS  DISEASES 


BEING  A  COMPENDIUM 


■OR   '11  IK   i;sK   oi 


Students    and    Practitioners    of   Medicine 


Charles  L.IDana,  A.M.,  M.D. 

Professor  of  Nervous  and   Mental   Diseases   in   the   New   York   Post-Graduate 
Medical  School,  and  in  Dartmouth  Medical  College  ;  Visiting  Physi- 
cian to  Rellevue  Hospital ;   Neurologist   to   the  Montefiore 
Home ;    ex-President    of    the    American    Neu- 
rological  Association,    etc. 


WITH    TWO    HUNDRED    AND    TEN    ILLUSTRATIONS. 


NEW  YORK 

WILLIAM  WOOD  &  COMPANY 

1892 


Copyrighted,  1S92, 
By  WILLIAM   WOOD  &  COMPANY 


ELECTROTYPED    AND    PRINTED  BV 
THE    PUBLISHERS'    PRINTING  COMPANY 
120   &    122    EAST    14TH    STREET 
NEW    YORK 


WL 
loo 
Dll  It 


PREFACE. 


It  is  the  object  of  the  author  in  this  treatise  to  present  the 
science  of  neurology  in  a  concise  yet  as  far  as  possible  complete 
form.  Each  subject  has  been  taken,  all  the  available  facts  re- 
garding it  ascertained,  the  writer's  own  experience  collated,  and 
with  the  data  thus  gathered  the  chapters  have  been  written. 
The  labor  involved  in  such  a  task  has  been  very  great,  but  I  am 
encouraged  to  believe  that  the  result  will  be  a  useful  one ;  for 
the  work  does  not  compare  or  compete  with  the  large  treatises 
which  are  already  in  the  field  nor  with  the  smaller  introductory 
text-books,  but  I  have  tried  to  furnisli  a  book  which  will  be  suit- 
able for  the  student  and  practitioner  and  not  valueless  to  the 
specialist. 

The  extreme  importance  of  a  knowledge  of  anatomy  has  led 
me  to  pay  especial  attention  to  furnishing  in  a  condensed  form 
the  most  recent  accessions  to  our  knowledge  of  this  subject. 
Starting  with  the  facts  that  can  be  gained  in  ordinary  anatomi- 
cal works,  the  student  can,  I  believe,  acquire  a  good  idea  of 
modern  neuro-anatomy  with  the  help  of  the  anatomical  chapters 
given  here. 

In  the  classification  of  nervous  diseases  and  the  description  of 
their  pathology,  I  have  tried  to  apply  the  modern  knowledge  of 
general  pathology  as  modified  by  bacteriology.  Tbis  I  have 
done  conservatively,  yet  not  less  than  in  my  opinion  is  absolutely 
demanded.  A  good  deal  of  havoc  will  be  wrought  eventually 
in  our  conception  of  the  nature  of  nervous  diseases  by  the  newer 
pathological  doctrines;  1  have  made  as  little  change  as  was  con- 
sonant with  undeniable  facts. 

The  limits  placed  upon  me  have  made  it  impossible  to  furnish 
a  bibliography  or  to  give  due  credit  to  every  original  investiga- 


IV  PREFACE. 

tor.  Full  references  to  literature  are  to  be  found  in  the  works  of 
Hirt,  Erb,  SeeligmilUer,  Ross,  and  Gowers. 

In  many  topics  I  have  been  much  helped  by  valuable  mono- 
graphs of  my  American  colleagues.  While  a  part  of  these  are 
credited  to  their  proper  source  in  the  text,  I  feel  that  I  ought  to 
refer  here  to  some  of  the  articles  that  have  been  of  special  service 
to  me.  They  include  monogra^Dhs  on  Spinal  and  Brain  Tumors 
by  Mills  and  Lloyd;  on  Cerebral  Palsies  of  Children  by  B.  Sachs; 
on  Muscular  Dystrophies  and  Writers'  Cramp  by  G.  W.  Jacoby 
and  by  M,  Lewis ;  on  Aj^hasia,  Cerebral  and  Spinal  Localizations 
by  M.  Allen  Starr;  on  Cranial  Temperatures  and  on  ]S'euras- 
thenia  by  L.  C.  Gray;  on  Degenerative  Neuritis  by  W.  H.  Les- 
zynsky ;  on  Poliomyelitis  by  Wharton  Sinkler ;  on  Craniometry 
and  Cranial  Deformities  by  F.  Peterson  and  by  E.  D.  Fisher;  on 
Angioneurotic  (Edema  by  Jos.  Collins ;  on  Brain  Tumors  by  P. 
C.  Knapp,  and  on  Sclerosis  of  the  Cord  by  J.  J.  Putnam.  I  am 
indebted  to  Tourette's  recent  treatise  on  hysteria,  to  that  of  Fer6 
on  epilepsy,  and  to  the  annual  volumes  of  Bourneville  on  these 
subjects.  The  masterly  lectures  of  Charcot  and  the  treatises  of 
Ross,  Gowers,  Hammond,  Hamilton,  and  Putzel  have  necessarily 
been  freely  used.  In  the  anatomical  part  I  have  used  the  works 
of  Edinger,  to  whose  courtesy  I  am  joarticularly  indebted,  the 
treatise  of  Obersteiner,  and  many  monographs  by  Golgi,  Marchi, 
Cajal,  His,  Waldeyer,  and  others.  My  own  work  in  teaching 
anatomy  and  pathology  has  enabled  me  to  do  more  than  present 
a  compilation. 

I  must  finally  express  my  thanks  to  my  publisher,  Mr.  W.  H. 
S.  Wood,  for  his  patience  and  helpful  generosity  in  my  efforts  to 
make  my  work  a  production  that  would  be  creditable  to  Ameri- 
can neurology. 

To  the  Student. 

As  a  special  text-book  the  present  work  will  be  used  by  two 
classes  of  readers,  one  consisting  of  those  who  simply  consult  it 
for  reference  in  connection  with  their  cases,  the  other  composed 
of  students  who  desire  to  ground  themselves  systematically  in  a 
knowledge  of  neurology.  To  this  latter  class  I  venture  some 
advice  as  to  the  method  they  should  pursue.     Neurology  is  a 


PREFACE.  V 

difficult  branch  of  medicine  to  master,  nor  is  there  any  royal  road 
to  it.  Still,  it  can  be  made  comparatively  easy  if  its  study  is 
undertaken  in  a  proper  and  systematic  way. 

In  using  the  present  work,  the  student  should  first  refresh  his 
general  knowledge  of  nervous  anatomy  as  furnished  in  ordinary 
text-books.  He  should  then  go  carefully  over  the  anatomical 
descriptions  here  given  of  the  general  structure  of  the  nervous 
system  and  of  that  of  the  nerves,  spinal  cord,  and  brain.  A  thor- 
ough knowledge  of  anatomy  and  physiology  makes  clinical  neu- 
rology comparatively  easy,  and  in  fact  reduces  much  of  it  simply 
to  a  matter  of  logical  deduction. 

The  student  should  next  master  the  general  facts  of  nervous 
pathology,  symptomatology,  and  etiology,  for  he  will  find  com- 
mon laws  underlying  apparently  the  most  varying  phenomena. 
Finally,  he  must  begin  to  study  the  special  diseases.  The  num- 
ber of  these  is  very  great ;  in  the  present  work  I  have  described 
17G.  Many  of  these  are  rare,  and  it  would  be  wrong  for  the 
student  to  burden  his  memory  with  the  details  about  them.  He 
need  know  only  of  their  existence  and  general  physiognomy. 
There  are,  however,  according  to  my  enumeration,  about  65  ner- 
vous diseases  which  are  either  very  common  or  extremely  im- 
portant, and  it  is  these  that  the  student  should  master  and  make 
part  of  his  working  knowledge.  Since  the  distribution  and 
names  of  the  common  and  rare  diseases  may  be  a  useful  guide,  I 
append  here  a  table  and  a  list : 


Peripheral. 

Spinal  Cord. 

Brain. 

Functional. 

Totals. 

Common  and  im- 
portant nervous 
diseases 

31 
56 

27 

12 

16 

10 
11 

65 

Rare 

111 

87 

40 

28 

21 

176 

The  common  or  important  peripheral  nervous  diseases  are : 
General. — Neuritis,  multiple  neuritis,  degeneration,  neuralgia, 
parsesthesia  (5). 

Cranial. — Anosmia,  optic  neuritis,  optic  atrophy,  ptosis, 
ophthalmoplegia,  abducens  palsy,  headache,  migraine,  trigem- 
inal neuralgia,  facial  spasm,  facial  palsy,  tinnitus,  vertigo, 
ageusia,  wry-neck  (16). 


VI  PREFACE. 

Spinal  Nerves.— Cervica]  neuralj^ia,  hiccough,  brachial  pal- 
sies, single  and  combined,  brachial  neuralgia,  intercostal  neu- 
ralgia, herpes  zoster,  lumbar  neuralgia,  sciatica,  leg  palsies  (10). 

Spinal  Cord. — Spina  bifida,  hemorrhage,  pachymeningitis, 
leptomeningitis,  poliomyelitis,  transverse  myelitis,  acute  and 
chronic,  secondary  degenerations,  locomotor  ataxia,  the  pro- 
gressive muscular  atrophies,  bulbar  palsy,  muscular  dystrophies, 
spinal  irritation  (13). 

Brain. — Malformations,  hyperaemia,  pachymeningitis,  lep- 
tomeningitis, simple,  tubercular,  and  epidemic,  abscess,  hemor- 
rhage, embolism,  thrombosis,  children's  palsies,  syphilis  (12). 

Functional. — Epilepsy,  hysteria,  the  tics,  chorea,  tetanus, 
neurasthenia,  spermatorrhoea,  exophthalmic  goitre,  occupation 
neuroses,  paralysis  agitans  (10). 


TABLE  OF  CONTENTS. 


PART  I. 

General   Description   of  the   Nervous   System, 
ITS  Anatomy  and  Diseases. 

CHAPTER  I. 

PAGE 

General  Anatomy  of  the  Nervous  System,     .        1 

CHAPTER  II. 

General  Description  of  Diseases  of  the  Ner- 
vous System. 

Method  of  studying, 15 

General  symptomatology  and  technical  terms,        ...      16 

CHAPTER  III. 

Diagnosis  and  Methods  of  Examination. 

Pliysiognomy  and  stigmata, 23 

Disorders  of  motility, 27 

Disorders  of  sensation 34 

CHAPTER  IV. 

The  Causes  and  Pathology  of  Nervous  Diseases. 

Etiology, '^^ 

Pathology, 43 

CHAPTER    V. 

Treatment,   Hygiene,  Prophylaxis. 

General  hygiene,  diet,  exercise 47 

Hydrotherapy, 49 

Climate, 53 

Electrotherapy, 53 


vm 


CONTENTS. 


PART   11. 

Anatomy  and  Diseases  of  the  Cerebro-Spinal 
Nerves. 


CHAPTER  VI. 
General  Diseases  Affecti>'g  THE  Cerebro-Spixal  Nerves. 


Hyperaeinia,  anaemia,     . 

Degeneration, 

Inflammation. 

Of  single  nerves, 
Multiple  neuritis,    . 

Functional  disorders,    . 
Neuralgia, 

Paraesthesic  neurosis. 
Aero-neuroses. . 

Tumors  of  nerves,  . 


CHAPTER   VII. 
Axatomy  of  the  Craxial  Nerves, 

CHAPTER  VIII. 
Diseases  of  the  Cranial  Nerves. 


Olfactory, 

Optic, 

Motor  nerves  of  the  eye 

Trigeminus,     . 

Headaches, 

Neuralgias, 
Facial, 
Auditory, 

Tinnitus,  . 

Vertigo,     , 
Glosso-pharyngeal 
Vagus, 

Hypoglossal,  . 
Spinal  accessory, 

Wrv-neck, 


CH 
Diseases  of 
Classification, 

Anatomy  of  cervical  grouj), 
Diseases,  . 


\PTER   IX. 

the  Spixal  Nerves. 


PAGE 

04 
Go 

68 
69 
TO 

80 
81 

84 
85 


02 


107 
108 
11 J 
120 
121 
128 
132 
•38 
138 
141 
146 

;47 

147 
48 
118 


153 
153 
155 


CONTENTS. 


IX 


Anatomy  of  brachial  group, 

Diseases,  . 
Anatomy  of  dorsal  group, 

Diseases,  . 
Anatomy  of  lumbar  group, 

Diseases,  . 
Anatomy  of  sacral  group. 

Diseases,  . 
Tabular  summaries, 


PAGE 

158 
160 
1G8 
168 
170 
170 
173 
173 
178 


PART   III. 

AXATOMY   A^D   DISEASES    OF   THE   SPIXAL   CORD. 
CHAPTER  X. 

AXATOMY  AND   PHYSIOLOGY  OF   THE   SPIXAL   CORD,    .      180 

Blood  supply, 193 

CHAPTER  XL 
Diseases  of  the  Spinal  Cord. 


General  etiology,  symptoms,  etc.,      .... 

.     196. 

Classification  of  diseases 

.     197 

Malformations,       ....                 ... 

.     197 

Spinal  hemorrhage, 

.     200 

Caisson  disease, 

.     202 

Anaemia  and  hypersemia, 

.     203 

Meningitis, 

.     205 

CHAPTER  XII. 

Inflammations  of  the  Spinal  Cord. 
Classification, 
Acute  myelitis. 
Chronic  myelitis,    . 
Anterior  poliomyelitis, 
Landry's  paralysis, 


CHAPTER  XIII. 

Degenerations  of  the  Spinal  Cord. 
Classification, 
Locomotor  ataxia. 
Combined  scleroses, 
Lateral  sclerosis,    . 
Secondary  degenerations, 


210 
210 
216 
220 

227 


22a 

231 
248 
257 
259 


CONTENTS. 


CHAPTER    XIV. 

The  Progressive  MrscvLAR  Atrophies  and 
Dystrophies. 


PAGE 

Classification 

.     261 

BuH)ar  iiaralysis, 

.     262 

DiH'hemie-Aran  type 

.     263 

l-t'y:tyi)o 

.     268 

Auiyotrophic  lateral  sclerosis 

.     268 

Musi-iilar  dystrophies 

.     209 

CHAPTER   XV. 

Tumors  and  Caa'ities  of  the  Spinal  Cord- 
Functional  Diseases. 

Tmiiors 

Cavities 

Syrinj^o-iiiyelia 

Functional  diseases: 

Spinal  irritation 

Spinal  exhaustion 


277 
280 
281 

286 

288 


PART    lY. 

AXATOMY   AXD    DISEASES    OF    THE   BrAIN. 

CHAPTER  XVI. 

Anatomy  of  the  Brain,         .        .        .290 
Physiology  and  localization, 317 

CHAPTER  XVII. 

Diseases  of  the  Brain. 

General  symptoms, ,329 

Malformations ;j33 

Meningitis, ;]34 

CHAPTER   XVIII. 

Diseases  of  the  Brain  Substance. 

Hypera'mia  and  anji^nia .  344 

Inflammation,  abscess^, 340 

The  ajioplexies  : 

Hi'morrhagc 353 

Emiiolism,  throndjosj.s 3(jo 

Children's  palsies, 3(j.-) 


CONTENTS. 


XI 


CHAPTER    XIX. 

Deqexeratioxs  and  Scleroses. 
Multiple  sclerosis, 

CHAPTER  XX. 

Tumors  of  the  Braix— Syphilis. 

Tumors, 

Syphilis  of  the  nervous  system, 


PAGE 

374 


381 
396 


PART  Y. 

Functional  Nervous  Diseases. 


CHAPTER  XXI. 

Fuxctioxal  Nervous  Diseases. 

Classification, 

The  degenerative  neuroses: 

Epilepsy, 

CHAPTER  XXII. 

The  Degenerative  'Nbuhosbs— Continued. 
Hysteria, 

The  spasmodic  tics, 
Paramyoclonus,     . 
Thomsen's  disease, 
Paramyotonia, 
Akinesia  algera,     . 


CHAPTER    XXIII. 

The  Acquired  Neuroses. 


Chorea, 

Tetanus, 

Tetany, 


CHAPTER  XXIV. 

The  Acquired  Neuroses— Cow^mt^ecZ. 
Neurasthenia, 
Nervous  women,    . 
Sexual  neuroses,     . 
Traumatic  neuroses. 
Exophthalmic  goitre, 


403 
403 


416 
431 
432 
433 
434 
434 


436 
442 
443 


446 
452 
457 
460 
462 


xu 


CONTENTS. 


CHAPTER   XXV. 
The  Acquired  Neuroses— Cow^«mec?. 
The  occupation  neuroses 


PAGE 

408 


CHAPTER    XXVI. 

The  Late  Degenerative  Neuroses. 
Paralysis  ajjritans, 

CHAPTER    XXVII. 

Trophic  axd  Vasomotor  Neuroses. 

Progressive  facial  hemiatrophy,  .... 

Acromegaly 

Antrioneurotic  cedema 


478 


484 

485 

487 


CHAPTER   XXVIII. 
The  Disorders  of  Sleep. 


Insomnia, 
Niglitmare, 
Pavor  nocturnus. 
Sleep  drunkenness 
Somnambulism, 
HypnotisH),     . 
Narcolepsy,     . 
Catalepsy, 
Sleeping  sickness, 
Sleep-accidents, 


490 
4913 
495 
495 
49G 
497 
500 
501 
502 
50a 


CHAPTER  XXIX. 

Cranio-Cerebral  Topography, 


General  index. 


505 
509 


Diseases  of  the  Nervous  System. 


CHAPTER  I. 

GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM. 

I  SHALL  describe  here,  first,  the  fundamental  constituents  of 
the  nervous  system,  and  next  tlie  general  facts  with  regard  to 
their  arrangements. 

The  nervous  system  is  derived  from  the  epiblastic  layer  of  the 
developing  ovum,  and  its  constituents  are  modifications  of  epi- 
thelial cells.  These  cells  in  the  embryo  are  of  tAvo  kinds :  neuro- 
blasts, which  develop  into  nerve  cells  and  fibres ;  and  spongio- 
blasts, which  develop  into  a  supporting  structure  called  neuroglia 
(His). 

The  nervous  system  is  composed  of — 

(a)  Nervous  tissue  proper,  viz. :  nerve  cells  and  nerve  fibres, 
forming  together  nerve  units  or  neurons;  and  neuroglia. 

(&)  Non-nervous  tissue,  viz. .  connective  tissue,  blood-vessels, 
lymphatics,  and  epithelium. 

These  tissues  are  united  together  to  form  a  central  nervous 
system,  consisting  of  the  brain  and  spinal  cord,  and  Bi,  peripheral 
7iervous  system,  consisting  of  nerve  fibres,  collections  of  nerve 
cells  called  nerve  ganglia,  and  structures  attached  to  the  termi- 
nations of  the  nerves,  called  end-organs. 

The  Nerve  Cells  or  Gangliox  Cells.  — /S/ittpe,  —  They 
are  of  various  shapes,  differing  in  different  parts  of  the  nervous 
system.  They  are  oftenest  irregularly  spheroidal,  pyramidal, 
spindle  or  flask  shaped.  They  give  off  processes  or  poles,  and 
are  classified  usually  in  accordance  with  the  number  or  arrange- 
ment of  these.  There  are  four  kinds,  viz. :  (1)  multipolar;  (2)  bi- 
polar; (3)  unipolar;  and  (4)  small  nuclear.  The  multipolar  cells 
are  the  common  type. 

iSize.—They  vary  much  in  size.  The  larger  cells  are  about  ^i^ 
inch,  the  smallest  3  5V0  inch,  in  diameter. 

Structure.— The  nerve  cells  are  composed  of  a  protoplasmic 
body,  containing  a  nucleus  and  nucleolus.  The  protoplasm  of 
the  body  appears  granular,  and  sometimes  striated  or  reticulated. 


2  DISEASES   OF  THE   NERVOUS   SYSTEM. 

It  often  contains  yellowish  pigment.  The  nucleus  is  apparently 
reticulated.  The  processes  are  given  off  in  various  directions. 
In  all  developed  nerve  cells,  one  or  more  of  the  processes  is  pro- 
longed; it  then  receives  a  myelin  sheath  and  becomes  a  nerve 
fibre.  This  is  called  tlie  nervous  or  axis-cylinder  process.  All 
nerce  fibres  are  sifnpli/  ])?'oIongations  of  nerve-cell  processes  and 
are  really  parts  of  nerve  cells.    The  nervous  process  sends  off 


Fig.  1.— Mi'LTipoLAR  Cell  of  First  or  Motor  Type  OIarchi).  showing 
nervous  process  and  collaterals 

lateral  fibres  at  right  angles  as  it  passes  out,  and  farther  on, 
when  It  becomes  a  nerve  fibre,  it  sends  off  other  processes;  these 
are  called  collaterals  (Golgi,  Cajal).  It  ends  finally  in  a  brush- 
like fibrillation  called  the  "end-brush.''  The  other  processes  of 
nerve  cells  are  called  protoplasmic.  They  connect  with  the 
blood-vessels  and  lymi)hatic  spaces  and,  perhaps,  have  a  nutrient 
function.  They  do  not,  at  any  rate,  connect  with  other  nerve- 
cell  proces.ses.  Multipolar  cells  are  said  (Golgi,  Yon  Monakow) 
to  be  of  two  types— motor  and  .sensory.     In  the  cells  of  the  motor 


GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM.     3 

type  the  nervous  process  passes  directly  into  the  axis  cyhnder 
of  a  nerve.  In  the  sensory  type  the  process  passes  first  into  a 
jDlexus  of  fibres,  out  of  which  a  single  nerve  finally  emerges. 

Some  multipolar  and  most  bipolar  cells  give  off  two  nervous 
processes ;  one  of  these  may  be  medullated,  the  other  not.  Many 
nerve  cells  of  the  peripheral  ganglia  have  a  membranous  sheath 
or  capsule  continuous  with  the  sheath  of  the  nerve.     The  cells 


Fig  2  —Multipolar  Cell  of  Second  or  Sensory  Type  (Marchi),  showing 
nervous  process  and  collaterals 

of  the  central  nervous  system  have  no  capsules.  The  shape  and 
structure  of  the  various  cells  are  best  shown  by  the  accompany- 
ing cuts.  The  location  of  the  different  kinds  of  cells  is  as  fol- 
lows : 

Multipolar  cells  are  found  in  the  cortex  cerebri,  basal  ganglia, 
and  central  gray  of  the  spinal  cord  and  medulla,  and  in  some 
peripheral  ganglia. 

Bipolar  cells  in  Clark's  column  and  intermediate  gray  of  the 
cord,  and  in  the  posterior  spinal  ganglia. 


4  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Unipolar  colls  in  the  posterior  spinal  and  sympathetic  ganglia. 

Small  nuclear  cells  and  flask-shaped  or  Furkluje's  celh  are 
found  in  the  cerebellum. 

Besides  these,  there  are  described,  in  the  brain  cortex,  angular, 
granular,  pyramidal,  globose,  and  spindle  cells. 

Thk  nkrvk  fibres  of  the  nerve  centres  are  found  chiefly  in 
the  white  tissue  or  white  matter.  In  the  periphery  they  form 
the  nerve  proper  of  gross  anatomy. 

Tht'  peripheral  nerve  is  composed  of  bundles  of  nerve  fibres 


// 


FiQ.  3.  Fig.  4. 

Fig.  3.— Mi'LTipoLAR  Cell,  showing:  processes,  reticulum,  nucleus  and  nucleolus. 
d,  Pigment  (Nissl). 

Fio.  4.— MrLTiPoiJVR  (PuRKiNJE)  Cell  from  Cerebellum,  a,  Body;  6,  nervous 
proceiis;  c,  protoplusinic  procfsses. 

called  nerve  fasciculi.  It  is  surrounded  by  a  connective-tissue 
sheath  called  the  sheath  of  Henle,  or  epineurium.  From  this 
sheath,  connective-ti.ssue  fibres  pass  in  and  surround  the  fascic- 
uli. The  sheath  of  the  fa.sciculus  is  called  the  perineurium. 
From  the  i)erin('urium,  strands  of  connective  tissue  run  in  among 
the  ultimate  nerve  fibres,  forming  the  endoneurium.  Lymphatic 
spaces  lined  with  endothelium  exist  in  the  layers  of  the  peri-  and 
endo-neural  sheaths.  In  the  nerve  centres,  the  nerve  fibres  have 
no  regular  sheaths,  but  are  supported  by  a  connective-tissue  and 
neuroglia  framework.     The  nerve  fibre  is  a  long  fine  strand  of 


GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM.     0 

tissue  varying  in  diameter.  It  may  be  white  or  gray  according 
to  its  structure.  It  is  comiDOsed  from  within  out  of  (1)  an  axis 
cyhnder,  (2)  a  myeUn  sheath,  and  (3)  a  neurilemma.  (1)  The  axis 
cylinder  is  the  essential  iDart  of  the  nerve.  It  is  the  prolonga- 
tion of  one  of  the  processes  of  a  nerve  cell  and  consists  of  proto- 
plasm.    It  is  itself  made  up  of  fine  fibrillse  (primitive  fibrillae) 


^ 


^'^^ms^ 


Fig.  5.— Umpolah  Cell,    a,  Bodj",  6,  capsule  ;  c,  process. 

which  run  longitudinally.  By  means  of  reagents,  a  transverse 
striation  can  be  seen  also.  (2)  The  myelin  sheath,  medullary 
sheath,  or  sheath  of  Schwann  surrounds  the  axis  cylinder.  It  is 
composed  of  a  semi-fluid,  fatty  substance,  which  chemically  con- 
sists of  lecithin,  neurin,  and  some  cholesterin.  It  varies  much  in 
thickness,  and  this  is  the  jorincipal  cause  of  the  different  sizes  of 


Fig.  6.— From  a  Transverse  Section  through  the  Sciatic  Nerve,  ep.  Epi- 
neurium;  p,  perineurium;  n,  nerve  fibres  constituting  a  nerve  bundle  or  fasciculus 
in  cross-section;  /,  fat  tissue  surrounding  the  nei"ve  (Klein). 

nerves.  The  myelin  sheath  is  interrupted  at  regular  intervals  by 
constrictions  called  the  "  nodes  of  Ranvier."  These  constrictions 
involve  the  myelin  sheath  alone.  The  axis  cylinder  passes  through 
and  the  outer  sheath  (neurilemma)  passes  over  it.  There  is  a  lit 
tie  granular  matter  at  the  point,  called  intercellular  cement.  The 
nerve  fibres,  if  they  divide,  always  do  so  at  a  node  (Fig.  10).     The 


6 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


part  between  two  nodes  is  called  a  nerve  segment.     In  each  sej2:- 
ment  there  is  an  oval  nucleus  imbedded  in  the  myelin  sheath. 

The  nodes  are  about  1  mm.  apart. 

The  myelin  sheath  is  probably  de- 
veloped, like  the  axis  cylinder,  from 
the  epiblast,  and  is  closely  related 
nutritionally  to  the  axis  cylinder, 
which  it  protects  and  isolates.  Be- 
tween it  and  the  axis  cylinder  Mauth- 
ner  describes  a  membranous  sheath 
(a  X  i  s  -  c  y  1  i  n  d  e r  sheath).  Another 
sheath  is  said  to  be  between  it  and 
the  neurilemma  (medullary  sheath). 
By  means  of  certain  reagents,  oblique 
lines  (incisures  of  Schmidt)  or  a  retic- 
ular appearance  may  be  developed 
(network  of  Gfedvelst).  These  appear- 
ances are,  perhaps,  artificial.  (3)  The 
neurilemma  or  primitive  sheath  is  a 
delicate  homogeneous  covering  form- 
,  ing  the  outermost  sheath  of  the  nerve. 
It  is  of  connective-tissue  origin.  The  sheath  is  absent  in  the  fibres 
of  the  central  nervous  system  and  in  some  fibres  of  the  periphery. 


Fio.  7.— Diagram  showing  the 
Different  Parts  of  the  Nerve. 
From  without  inward  we  liave  : 
1,  Nerve  with  epineurium;  2, 
nerve  fasciculus,  with  perineu- 
rium; .3,  nerve  fibre  and  endo- 
neurium:  4,  neurilemma,  myelin 
sheath,  axis  cylinder,  primitive 
fibrilhe. 


Fio.  ^-  Fio.  9. 

Fio.  H.— MEDVLLATKn  Nerve  Fibre,    a,  Axis  cylinder; 


Fig.  10. 
I,  nucleus  ;  m,  medullary 


sheath;  c,  node  of  Itanvier. 

Fio.  9.— Medullatei)  N'ervk  Fibre,  showing' axis  cylinder,  nuclei  of  medullary 
she^ith.  nodes,  and  obliciuc  incisures  of  S'chiiiidt. 

Fig.  10.— Medullated  Nerve  Fibre,  showing  mode  of  division. 


GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM. 


Variations  in  the  Types  of  Fibres. — In  accordance  with  the 
arrangement  of  the  sheaths  of  the  nerve  fibres,  several  kinds 
are  described.  The  principal  types  are  the  medullated  and  non- 
medullated. 

Medullated  nerve  fibres  make  up  the  bulk  of  the  white  matter 
of  the  brain  and  cord  and  cerebro-spinal  nerves.  They  consist 
of  a  myelin  sheath  and  axis  cylinder,  and  may  or  may  not  have 
a  neurilemma. 

Fibres  with  myelin  sheath,  but  without  a  neurilemma,  make 
up  the  white  matter  of  the  central  nervous 
system. 

Non- medullated  fibres,  or  fibres  of  Re- 
mak,  occur  principally  in  the  sympathetic 
system,  but  tliey  are  also  found  in  the  cere- 
bro-spinal nerves.  They  are  grayish  and 
faintly  striated,  and  consist  of  axis  cylin- 
ders, wath  a  thin,  homogeneous,  nucleated 
sheath  lying  directly  upon  them.  This 
sheath,  however,  cannot  often  be  demon- 
strated (Schaefer). 

Naked  axis  cylinders  are  found  in  the 
peripheral  terminations  of  nerv^es  as  well 
as  in  the  brain  and  cord. 

Size. — The  nerve  fibres  are  of  two  kinds 
as  regards  size.  The  small  fibres  are  about 
Y2^o7  inch  in  diameter,  the  large  y^tu)  inch. 
The  small  fibres  are  connected  with  smaller 
cells,  and  either  run  a  shorter  course  or 
are  distributed  to  the  involuntary  muscu- 
lar fibres  of  the  blood-vessels  and  viscera. 

The  nerve  fibres  of  the  central  nervous 
system  give  off  "collaterals,"  i.e.,  small 
medullated  fibres  branch  out  at  right  angles 
and  pass  off  to  make  connections  in  an  un- 
known way  with  nerve  cells  or  other  fibres. 

These  fibres  and  those  of  the  nerve  roots  have  no  neurilemma, 
but  are  surrounded  with  neuroglia  tissue.  They  always  end  in 
a  brush-like  plexus  of  i^rimitive  fibrils,  which  surrounds  the 
nerve  cells  in  a  netw^ork. 

The  peripheral  nerve  fibres,  except  the  optic,  have  no  neuroglia ; 
they  terminate  in  fine  fibrill<e  among  epithelial  cells,  or  in  special 
end  organs. 

Connections  of  Nerve  Cells  and  Nerve  Fibres.— One  nerve  cell 
is  never  connected  directly  with  another,  so  far  as  anatomical 
investigation  can  show.  One  nerve  process  becomes  an  axis 
cylinder,  receives  a  myelin  sheath,  gives  off  collaterals,  and  finally 


Fig.  11.— Non-medulla  t- 
ED  Nerve  Fibre,  n,  Nu- 
cleus; b,  striations. 


8 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


breaks  up  into  a  fibrillary  "  end-brush  ''  surrounding  a  cell,  Ijut  not 
paiising  into  it.  There  is  physiological,  but  no  apparent  anatom- 
ical continuity  (Fig.  12). 

The  cell  and  its  nerve  fibre  and  end-brush  form  together  the 
nervous  unit  or  neuron.     The  typical  arrangement  of  a  neuron 

is  shown  in  Fig.  12. 

The  Neuroglia.  —  The  sup- 
porting tissue  of  the  peripheral 
nerves  is  connective  tissue  only; 
that  of  the  central  nervous  sys- 
tem is  connective  tissue  and,  in 
addition,  a  peculiar  substance 
called  neuroglia.  The  neuroglia 
or  supporting  tissue  of  the  ner- 
vous centres  is  derived  from  the 
epiblast.  It  is  composed  of  cells 
with  very  numerous  and  finely 
ramified  processes,  which  make  a 
supporting  netM'ork  about  the 
nerve  cells  and  fibres.  The  neu- 
roglia cells  are  known  as  "  spider 
veils  "  or  Deiter's  cells.  They  dif- 
fer somewhat  in  size  and  shape, 
but  not  in  general  characteris- 
tics. The  fibrillary  j^rocesses 
form  a  felt-like  network ;  and  in 
regions  where  there  is  much 
neuroglia  tissue,  this  looks  like 
a  iiomogeneous  matrix.  It  is, 
however,  made  ujd  of  the  fine 
fibrils.  These  connect  with  the 
■walls  of  the  blood-vessels.  In 
inflammatory  conditions  the 
cells  multiply,  swell  up,  and  as- 
sist in  carrying  off  irritating  pro- 
ducts (scavenger  cells  of  Lewis). 
Nerve  Units THRoroHoiT  THE  Nervois  Neuroglia  tissue  is  richlv  de- 
SvsTEM.      ],  Nerve    cell;    2    nervous   posited  about  the  centrarcanal 

pnxiess;    3,  collateral:  4,  eml-biush;  5,        . 

nerve  cell.  ^^'  ^"6  Spinal  cord,   in  the  sub- 

stantia gelatinosa,  beneath  the 
ependyma  of  the  ventricles  and  beneath  the  pia  mater  of  the 
brain  and  cord.  The  epithelial  cells  of  the  central  canal  and 
ependyma  of  the  ventricles  send  down  fine  processes  which  form 
a  minor  part  of  the  supporting  framework. 

Thk    Nox-NERVors    TissuKS.  —  TAe     J?/oocZ- TV.svse/6-. —The 
IK'riphcral  nerves  are  richly  supplied  with  blood.     Each  nerve  re- 


FlO.  I'-i.— I>IAORAM   .SHOWING  THE  NeU- 

noM  AND  Mode  of  Connectio.n'  between 


GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM. 


ceives  arterial  supply  from  many  different  branches,  but  al- 
ways from  the  same  general  source.  The  artery  passes  to  the 
nerve  sheath  obliquely,  then  divides  dichotomously  and  sends 
branches  a  long  distance  up  and  down  on  the  sheath.  It  may 
pierce  the  sheath,  however,  first,  and  then  divide,  as  above  de- 
scribed.    The  dichotomous  branches  send  off  arterioles  and  capil- 


ATP    VTP 


f$jp 


Fig.  14. 

Fig.  13.— Arteries  of  Sciatic  Nerve  (Quenu  and  Lejars). 

Fig.  14. — Venotts  Supply  of  Posterior  Tibial  Nerve.  N,  Nerve  ;  ATP, 
VTF,  vein;  MJP,  muscle;  B,  veins  to  muscle;  C,  B,  veins  to  nerve  (Que 
Lejars). 


artery; 
nu  and 


laries,  which  form  plexuses  about  the  nerve  fascicles.  These  are 
"the  interfascicular  arcades."  The  arteries  subdivide  in  such  a 
way  as  to  prevent  sudden  impact  of  a  large  blood  stream  into  the 
tissue  of  the  nerve.     In  this  respect  the  nerve  circulation  resem- 


10 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


bles  that  of  tlu'  l.niiii  and  .'onl.  The  veins  subdivide  dichoto- 
inously,  like  the  arteries.  They  freely  aiKistoniose  with  the  iims- 
cular  veins,  so  that  muscular  action  helps  nerve  circulation. 
The  veins  of  the  superlicial    nerves  connect  with  those  of  the 

deep  nerves. 

The  blood-vessels  of  the 
spinal  cord  and  brain  will  be 
described  later. 

Lymphatic  vessels  and 
spaces  are  found  in  the  epi- 
neurium  and  perineurium. 
There  are  no  distinct  lym- 
phatics in  the  fasciculi,  but 
lymph  spaces  probably  exist. 

The   General  Arraxge- 

mext  axd  fuxctioxs  of 

THE  Nervous  System. 

Having    described    the 

component  parts,  I  shall  noAV 

show  the  way  in  which  these 

parts   are  arranged  to  form 

the  nervous  system. 

The  nervous  system,  as 
already  stated,  consists  of— 

I.  A  central  part,  com- 
posed of  the  brain  and  spinal 
cord. 

II.  A  peripheral  part, 
composed  of  nerves,  periph- 
eral ganglia,  and  end  organs. 

I.  The  nerve  centres  are 
made  up  of  gray  and  white 
matter,  inclosed  in  mem- 
branes called  the  meninges. 
The  gray  matter  consists 
chiefly  of  nerve  cells  ar- 
ranged in  groups  or  masses.  The  white  matter  consists  of  nerve 
fibres  arranged  in  tracts,  strands,  or  columns. 

The  gray  matter  is  deposited  in  five  principal  places. 
The  niyelon,  or  central  gray  matter  of  the  spinal  cord,  and 
brain  Jixis,  extending  to  the  tuber  cinereum. 

The  corpora  dciitata,  ohvary  bodies,  and  red  nuclei. 
The  great  basal   ^'aiiglia,    viz.,  corpora  striata   composed    of 
lenticular  and  caudate  nuclei,  the  optic  thalami,  and  the  corpora 
quadrigemina. 


lKltl-AS(  ICI  I.AK   DlSTRIBl'TION   OF 
AUTERIES   (yuENU   AND   LeJAHS). 


GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM.    11 

Cortex  of  cerebellum. 

Cortex  of  cerebrum. 

Besides  these  collections  of  gray  matter,  there  are  minor  g:ang:lia 
in  the  pons,  cerebellum,  and  cerebrum,  which  will  be  referred  to 
later.  The  white  matter  connects  these  various  ganglionic  de- 
posits of  gray  matter  with  each  other  and  the  periphery. 

11.  The  peripheral  nervous  system  is  usually  described  as  con- 
sisting of  a  cerebro-spinal  and  a  sympathetic  part.  Both  por- 
tions, however,  are  alike  made  up  of  nerve  fibres  derived  from 
and  dependent  on  the  brain  and  cord.  Both  are  composed  of  nerve 
fibres  connected  in  their  course  with  peripheral  ganglia  and  ter- 
minating in  end  organs.  These  peripheral  ganglia  consist  of 
three  sets-  (1)  The  spinal  ganglia,  on  the  posterior  roots;  (2)  the 
vertebral  or  sympathetic  ganglia,  connected  chiefly  with  the  an- 
terior roots;  and  (3)  the  peripheral  ganglia  proper,  including  vaso- 
motor and  visceral  ganglia,  with  which  fibres  from  both  roots  are 
connected. 

The  nerves  which  run  between  centre  and  end  organs  carry 
nerve  impulses  both  ways.  They  are,  therefore,  divided  into 
the  afferent,  centripetal  or  in-going,  and  efferent,  centrifugal  or 
out-going.  The  old  division  into  motor  and  sensory  nerves  will 
not  answer,  for  we  know  that  there  are  many  out-going  nerves 
which  are  not  motor.     The  afferent  nerves  are — 

1,  The  sensory,  including: 

Nerves  of  general        \  Pain  nerves  or  pathic  nerves,  heat  and 

sensation.  (      cold  or  thermic  nerves. 

f  i  Contact, 

Nerves  of  Tactile,  including  ^  Pressure, 

•  1  '  Locality, 

special  -;  ^^  ^  ,  ^ 

i .  I  Jserves  of  muscular  sense, 

sensation.  I  ,         , 

I  jserves  of  special  sense  of  smell,  sight, 

L     taste,  hearing,  and  space. 

2.  Excito-reflex  nerves. 
The  efferent  nerves  are — 

1.  Motor  nerves,  going  to  voluntary  or  striped  muscles,  heart 
muscle,  smooth  muscle,  including  the  vaso-constrictor  and  dila- 
tor nerves. 

2.  The  secretory.  These  act  upon  glands.  Impulses  to  the 
blood-vessels  (vasomotor)  generally  accompany  the  secretory  im- 
pulses. 

3.  The  trophic. 

4.  The  inhibitory.  These  nerves  control  muscular  movements, 
secretion,  perhaps  also  nutrition. 

We  must  admit  that  afferent  and  efferent  impulses  take  place 
also  between  end  organs  and  certain  (so-called)  sympathetic 
ganglia.     In  other  words,  the  cerebro-spinal  axis  is  not  always  the 


12 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


only  oentre.     But   these  subordinate  and  peripheral  centres  are 
normally  in  connection  Avith  the  spinal  cord  and  may  be  influ- 
enced by  it  or  by  hiy;her  parts. 
There  are  also 

Inttrrentral  or  commissural   nerves,  which  connect  different 
ivarts  of  the  cerebro-spinal  system  together.     Some  of  these  con- 

-^  - nect  symmetrical  parts 

on  each  side  together. 
They  have  co-ordinat- 
ing function.  Others 
connect  higher  with 
lower  centres.  These 
latter  ar^  made  up  of 
ascending  and  descend- 
ing fibres.     Higher  cen- 

\    \    ..--'    tres  send  down  impulses 

by  the  latter,  which  may 
stimulate  or  inhibit 
lower  centres.  In  the 
peripheral  nervous  sys- 
tem w^e  have  also  end 
organs.  These  are  deli- 
cate and  in  some  cases 
complex  arrangements 
of  the  nervous  and 
other  tissue  at  the  per- 
iphery of  the  nerves. 
Their  object  is  to  allows 
the"  nerves  to  be  irri- 
tated by  special  stimnH 
which  Avould  not  other- 
Avise  affect  them,  e.g., 
light  or  sound.  Their 
object  is  also  the  proper 
utilization  of  efferent 
impulses  upon  other  tis- 
sues. 

There  are  end  organs,  therefore,  for  both  sensory  or  afferent 
and  for  efferent  nerves. 

The  end  organs  of  the  afferent  nerves  are — I.  Eye.  II.  Ear. 
III.  Taste-buds.  IV.  Cori)uscles  in  the  Schneiderian  membrane. 
V.  Various  tactile  cells  and  bodies.  VI.  The  space-sense  organ. 
For  the  efferent  nerves— I.  Neuro-muscular  corpuscles  in  the 
voluntary  muscles.  II.  Local  ganglia  about  the  arteries.  III. 
Ijocal  ganglia  in  the  glands.  Trophic  end  organs  are  not 
known,      in  many  cases   the  end  organ  is   nothing  but  the  ter- 


FiG.  If).— Diagram  showing  the  Arrangement 

OF  THE  NeI-RON-S  OR  NkRVE  UNITS  IN  THE  ARCHITEC- 
TURE OF  THE  Nervois  Sy.stem.  M.  N^uroHS  I.  and 
//..  Motor  neurons;  S.  Neiirons  /.,  i/.,  III.,  sensory 
neurons;  A.  Jieuron,  associative  or  commissural 
neuron. 


GENERAL  ANATOMY  OF  THE  NERVOUS  SYSTEM.    13 


minal  fibres  of  the  nerve.  These  lose  both  medullary  sheath  and 
neurilemma,  leaving  only  the  axillary  cylinder.  These  cylinders 
split  up  into  terminal  plexuses,  or  else  without  splitting  pass  be- 
tween and  around  the  cells  which  they  are  to  affect. 

The  nerves,  centres,  and  end  organs  thus  described  may  be 
arranged  in  mechanisms,  each  mechanism  subserving  a  special 
function.  These  form  the  mechanisms  of  the  nervous  system 
proper,  and  those  of  the  other  organs  of  the  body. 

They  are  as  follows : 


f      I.  The  psychical  mechanism  or  mind. 


Cerebro- 
spinal. 


Visceral 
mechanisms. 


II. 

III. 

IV. 

V. 

r  The  secretory  mechanism. 
!  The  trophic  mechanism. 
I  The  thermic  mechanism. 
[  The  vasomotor  mechanism. 


The  automatic  mechanisms  or  the  mechanism 

of  inherited  and  acquired  aptitudes. 
The  sensory  mechanism. 
The  voluntary  motor  mechanism. 
The  reflex  mechanism. 


Compound 

neuro- 

mechanisms. 


Various  of  the  simpler  mechanisms  are  combined  to  form  those 
more  complex.  Thus  the  automatic  and  psychical  mechanisms 
embrace  in  their  activity  other  mechanisms  of  lower  grade. 

In  the  same  way  mechanisms  are  combined  for  the  regulation 
of  visceral  functions.     Thus  we  have — 

I.  The  cardiac  neuro-mechanism— a  combina- 
tion of    automatic,    reflex,    inhibitory, 
motor,  and  sensory  fibres  and  cells. 
II.  The  respiratory  mechanism. 

III.  The  mechanisms  of  the  digestive  tract. 

IV.  The  renal  mechanism. 
V.  The  thermal  mechanism. 

VI.  The  skin  and  sweat  mechanism. 
VII.  The  vesical  mechanism. 
I  VIII.  The  sexual  mechanism. 

In  the  working  of  these  mechanisms  the  nerve  cell  is  the  agent 
which  generates  the  energy  or  nerve  force,  by  w^hich  impulses  are 
started,  controlled,  and  distributed.  The  larger  the  nucleus  of 
the  cell  in  proportion  to  its  protoplasmic  body,  the  more  stable 
or  less  sensitive  the  cell.  The  larger  the  amount  of  protoplasm 
relatively  to  the  nucleus,  the  more  active  the  discharging  power 
of  the  cell.  The  nerve  fibres  conduct  impulses  generated  by  nerves. 
These  impulses  travel  at  the  rate  of  about  100  to  120  feet  per  second. 
It  is  less  in  visceral  nerves  (25  to  30  feet  per  second).  There  are  no 
electrical  currents  in  normal  living  nerves  (Landois)  except  when 


14 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


an  iiiipulso  travels  along  them.  Then  an  electrical  current 
travels  along  with  the  impulse.  It  is  called  the  current  of  negative 
variation.  The  irritability  or  excitabiUty  of  a  nerve  is  the  power 
it  has  of  responding  to  a  stimulus.  When  a  constant  electrical 
current  is  passed  along  a  nerve  its  irritability  is  modified.  This 
modified  condition  is  called  electrotonus. 

When  a  nerve  impulse  passes  up  an  afferent  nerve  and  is  then 
reflected  along  an  afferent  nerve,  it  is  called  a  reffe.v  action.  The 
time  required  for  this  process  is  called  the  reaction  time.  This 
averages  from  0.125  to  0.2  of  a  second. 

CuKMir^THY. — The  nervous  tissues  are  alkaline  in  reaction,  but 
acidity  rapidly  increases  on  activity.  Acidity  is  due  to  lactic 
acid.  It  is  greater  in  the  gray  matter.  The  percentage  of  water 
is  shown  in  the  accompanying  table,  compiled  from  Hallibur- 
ton's figures: 


Percentage  of  Water. 

Portion  of  Nervous  System. 

Fcetus. 

Age. 
20-30. 

70-94. 

Gray  matter 

!-  ««  ; 

83 
69 

&4 
72 

White  matter 

74 

68 

Nerves  have  the  least  water,  gray  matter  of  the  brain  most. 

Inorganic  salts  vary  in  amount,  but  average  0.5  per  cent.  PO4 
is  the  largest  single  constituent  of  the  brain ;  potassium  is  next 
(Geoghegan). 

The  nervous  system  is  composed  of — 

1.  Proteids,  which  make  up  about  half  the  solids  in  gray  mat- 
ter, one-fourth  those  in  white  matter,  and  one-third  those  in 
nerves. 

2.  Albuminoids,  which  are  neuro-keratin  and  nuclein. 

3.  Phosi)horized  constituents  known  as  protogon  and  lecithin. 

4.  Nitrogenous  bodies  of  unknown  composition  called,  5,  cere- 
brins;  (5,  cholesterin,  which  is  a  monatomic  alcohol  abundant  in 
white  matter;  7,  extractives;  and  8,  inorganic  salts. 

The  following  tal)le  shows  the  proportions  of  the  different 
organic  constituents  of  the  brain  (Petrowskv): 


Gray  matter. . 
White  matter. 


Proteids.  Lecithiu.  Cerebriu 


5.5.37 
24.7',' 


17.24 

9.90 


0.53 
9.55 


Choles- 
terin 
and  Fat. 


IS.  68 
51.91 


Other 
Organic       Salts. 
Mattel-. 


C.7I 
3.34 


CHAPTER   II. 

GENERAL  DESCRIPTION   OF  DISEASES   OF  THE 
NERVOUS   SYSTEM. 

The  Method  of  Studyixg  Nervous  Diseases. 

In  studying?  the  vital  phenomena  of  the  human  body,  we  learn 
first  its  normal  structure  and  functions.  Then  when  diseased  we 
note  the  new  phenomena  which  have  developed,  the  causes  which 
produced  them,  and  the  anatomical  changes  lying  back  of  them ; 
we  group  our  facts  and  give  the  disease  a  name.  Finally,  we  ap- 
ply the  methods  by  which  the  disorder  can  be  relieved  and  future 
attacks  prevented.  In  fine,  we  investigate  our  subject  just  as  we 
study  any  branch  of  natural  history.  Our  study  divides  itself, 
therefore,  into — 

Normal  Anatomy  and  Physiology. 

Symptomatology,  a  study  of  the  morbid  phenomena. 

Etiology,  a  study  of  the  causes. 

Pathology,  under  which  we  include  a  study  of  the  morbid 
anatomy  and  physiology. 

Diagnosis,  or  the  method  of  differentiating  the  different  groups 
of  diseases. 

Prognosis,  a  forecast  of  the  future  course  of  the  malady. 

Treatment  and  Prophylaxis. 

Again,  although  nervous  diseases  exhibit  many  phases  and 
have  many  different  morbid  changes  behind  them,  there  are 
certain  features  common  to  all.  It  simplifies  their  study,  there- 
fore, to  learn  first  what  these  general  features  are,  just  as  a  per- 
son can  better  survey  and  plot  out  a  country  in  detail  if  he 
knows  certain  general  facts  about  its  boundaries  and  topography. 
Hence  I  shall  first  present  in  a  general  way  an  outline  of  the 
fundamental  facts  that  touch  more  or  Jess  on  all  forms  of  nervous 
disease.     My  first  chapters  will  be  devoted  to — 

General  Anatomy  and  Physiology,  Symptomatology,  Etiology, 
Pathology.  Diagnosis,  Prognosis,  and  Treatment. 

The  subject  of  anatouiy  and  physiology  has  already  been  briefly 
presented.     We  shall  now  take  up 


IG  DISEASES  OF  THE   NERVOUS   SYSTEM. 


Symptomatology. 

I  shall  bejjin  ^vith  a  definition  of  certain  terms  that  are  fre- 
quently used. 

Neuroloyy  is  the  science  of  nervous  diseases. 

I\sychiatry  is  the  science  of  mental  diseases. 

A  neurosis  is  a  morbid  nervous  state.  The  term  as  sometimes 
used  is  restricted  to  morbid  nervous  states  of  functional  charac- 
ter. This  is  not  strictly  correct,  and  in  speaking  of  neuroses  I 
give  it  the  general  meaning. 

A  psychosis  is  a  morbid  mental  state,  and  is  nearly  identical 
with  an  insanity,  but  has  a  broader  meaning. 

The  vital  activities  of  the  nervous  system  are  shown  in  the 
phenomena  of  the  mind,  in  muscular  movements,  sensation,  con- 
trol of  blood-vessels  and  secreting  glands,  in  modifications  of 
nutrition,  of  temperature,  and  visceral  action.  The  disorder  of 
any  one  of  these  functions  produces  a  train  of  symptoms  which 
receives  a  name  in  accordance  with  its  character  and  class. 

Disorders  of  motion  are  called  kinesio-uviiroses;  those  of  sensa- 
tion, asthesio- neuroses. 

Correspondingly  we  have  tro2:>ho-neii7'oses,  thermo-neiwoses, 
vasomotor,  secretory,  and  visceral  neuroses. 

When  mental  or  nervous  functions  are  disordered,  there  is  an 
increase,  decrease,  or  perversion  of  the  special  function  or  activ- 
ity. Certain  Greek  prefixes  are  used  to  indicate  this.  They  are : 
"  hyper,"  which  mean  excess;  "  hypo,"  meaning  diminution;  "a" 
or  "  an,"  which  means  absence;  and  "  para,"  which  means  perver- 
sion. 

So  we  have,  for  example,  hypericsthesiaor  excessive  sensibility; 
anfesthesia,  which  means  loss  of  sensation;  parsesthesia,  which 
means  perversion  of  sensation. 

From  the  foregoing  it  will  be  seen  that  the  classes  or  kinds  of 
nervous  symj)toms  are — 

1.  Mental  and  cerebral,  forming  psychoses. 

2.  Motor  and  reflex,  forming  kinesio-neuroses. 

3.  Sensory,  forming  sesthesio-neuroses. 

4.  Trophic,  forming  tropho-neuroses. 

5.  Vasomotor  and  thermic,  forming  angio-neuroses  and  ther- 
mo- neuroses. 

G.  Secretory,  forming  secretory  neuroses. 

Combinations  of  these  groups  of  symptoms  may  affect  vari- 
ous organs.  They  are  called  mixed  neuroses.  A  disorder  may 
affect  certain  parts  of  the  body,  like  the  extremities— it  is  then 
called  an  acro-neurosis ;  or  certain  functions  hke  the  sexual  or- 
gans—it  is  then  called  a  sexual  neurosis. 


GENERAL   DESCRTPTION   OF   NERVOUS   DISEASES. 


ir 


K /^  Psychoses 


Aesthesioneuroses 


Kinesloneu  roses 


Secretory  &iropiii& 

"\4so«mofor 


Fig.  17.— Diagram  illustrating  the  Prin- 
ciple OF  THE  Classification  of  Ner- 
vous Symptoms. 


Combinations  of  mental  and  nervous  symptoms  form  psycho- 
neuroses. 

A  common  and  practical  division  of  nervous  symptoms  is  into 
the  objective  and  subjective. 

Objective  symptoms  are  those  which  can  be  observed  and  noted 
by  the  physician. 

Subjective  symptoms  are  those  which  are  felt  by  the  patient 
and  give  no  outward  sign.  Headache  is  a  subjective  symptom; 
atrophy  is  an  objective  one. 

The  particular  symptonjs   which  nervous  diseases  cause  are 
best  described  and  recorded 
under   the    several    heads 
given  above. 

1.  The  mental  symptoms 
include  all  those  found  in 
insanity, idiocy,  and  imbecil- 
ity, and  will  not  be  given  in 
detail  here. 

The  common  symptoms 
met  with  by  the  neurologist 
are  mental  irritability,  de- 
pression, emotional  excite- 
ment, morbid  fears,  voli- 
tional weakness  and  lack  of  self-control,  persistent  or  fixed  ideas, 
weakness  of  memory  and  of  power  of  concentration,  and  a  ten- 
dency to  hypnotic  and  somnambulistic  states. 

Certain  symptoms  due  to  disturbance  of  brain  function  are 
often  called  cv:/'e6r«/,  as  distinguished  from  mental.  They  are: 
vertigo,  disorders  of  equilibrium,  insomnia,  somnolence,  stupor, 
coma. 

Headache,  head  pressure,  and  similar  feelings  are  also  often  de- 
scribed under  the  head  of  cerebral  symptoms. 

2.  Motor  Symptoms. — The  symptoms  of  disordered  motility 
m^y  be  classified  as  follows : 

A.  Symptoms  of  exaggerated  motility  or  hyperkineses. 
a,  fibrillary; 

[  intentional,  or  tremor  on  motion, 
-]  tremor  in  rest, 
(  constant, 
tonic, 
clonic, 

f  co-ordinate  or  purposeful. 
Choreic  movements,  convulsive  tic,  athetosis. 
Muscular  tension  and  rigidity,   contracture,   myotonia,  myo- 
clonus. 

Forced  movements,  associated  movements. 

2 


Tremor : 

&,  tremor  proper 


Convulsions  or  spasms : 


18  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Exaggerated  reflexes,  clonus,  trepidation. 
B.  Symptoms  of  lessened  motility. 

Paralysis  and  ^  monoplegia, hemiplegia, 
paresis:       '(  paraplegia,  diplegia. 

Loss  of  reflexes,  superficial  and  deep. 

Tremor  is  the  result  of  a  disorder  in  the  tonic  innervation  of 
muscles.  Muscles  are  kept  normally  in  a  state  of  slight  tension 
by  rhythmical  impulses  from  the  brain  cortex  passing  down  at 
the  rate  of  about  twelve  per  second.  When  the  rhythm  and  force 
of  these  normal  impulses  are  interfered  with  we  have  tremor. 

The  simplest  form  of  tremor  is  one  in  which  the  normal  tonic 
imi)ulses  have  an  apparently  exaggerated  force.  This  causes  a 
fine  tremor  of  ten  to  fourteen  vibrations  per  second.  When  there 
is  an  Interruption  to  some  of  the  impulses  we  have  a  coarse  tremor. 
Here  the  vibrations  are  five  to  eight  per  second.  It  is  caused  by 
a  partial  or  complete  dropping  out  of  the  alternate  impulse. 

Various  technical  names  are  used  in  describing  the  tremors. 

We  have  the  fine  and  coarse,  as  described. 

Intention  tremor  is  one  that  occurs  on  voluntary  movement, 
and  is  oj^posite  in  kind  to  the  tremor  of  rest,  which  decreases  or 
ceases  on  voluntary  effort. 

The  term  paralytic  tremor  is  used  to  express  the  tremor  of  ex- 
haustion, and  the  term  spastic  tremor  that  of  exaggerated  motil- 
ity, as  in  the  tremor  of  a  Chill.  Ataxic  ti-emor  is  one  in  which 
inco-ordinate  movements  are  combined  with  the  tremor. 

Fihrillary  tremor  is  a  fine  twitching  of  the  individual  strands 
or  parts  of  muscles,  and  occurs  usually  when  they  are  wasting 
from  lack  of  neuro-trophic  influence. 

Convulsions  consist  of  abnormal  and  exaggerated  muscular 
contractions  occurring  in  rapid  succession.  Convulsions  may  be 
clonic,  i.e.,  the  muscles  rapidly  and  alternately  contract  and  relax 
in  an  exaggerated  and  irregular  way;  or  they  may  be  tonic,  i.e.., 
contracted  steadily  and  continuously.  When  a  tonic  muscular 
contraction  is  painful  it  is  called  a  cramp.  Convulsions  may  be 
co-ordinate.  In  this  case  the  patient  moves  the  limbs  and  body 
in  a  more  or  less  purposeful  way.  He  throws  himself  about  the 
bed,  jumps,  kicks,  strikes,  tears  the  clothes,  etc. 

Convulsions  are  usually  accompanied  with  loss  of  conscious- 
ness. 

CJioreic  momnient.s  sa-e  sudden  jerking,  twitching  movements 
of  different  groups  of  nmscles.  The  movements  are  purposeless 
and  are  not  under  control  of  the  will. 

Convulsive  r/c— When  a  choreic  movement  is  confined  to  cer- 
tain groups  of  nmscles  which  work  together  for  a  common  pur- 
l^ose,  like  those  of  the  face,  or  eyes,  or  larynx,  it  is  called  a  "  tic." 
The  movements  in  the  "  tics  "  are  more  definite  in  character  and 


GENERAL   DESCRIPTION   OF   NERVOUS   DISEASES.         19 

are  limited  to  muscles  physiologically  grouped  for  a  definite  func- 
tion. Thus  we  have  tics  of  the  muscles  of  expression,  or  of  respi- 
ration, or  speech,  or  locomotion, 

Atheto.sf'.s.— This  is  a  name  given  by  Hammond  to  a  peculiar 
form  of  movement  characterized  by  slow,  successive  flexion,  ex- 
tension, pronation,  and  supination  of  the  fingers  and  hand  and 
arm,  or  of  analogous  movement  of  the  toes  and  feet.  The  motion 
rarely  ceases  in  waking  hours  except  for  a  short  time.  The  con- 
tractions are  forcible,  steady,  and  even,  and  sometimes  painful. 
The  hand  assumes  characteristic  positions. 

A  contracture  is  a  tonic  muscular  spasm  of  long  duration,  i.e.^ 
days  or  months.  A  contracture  may  be  functional  or  organic ;  and 
in  order  to  test  this,  one  must  find  whether  it  ceases  during  sleep 
or  under  an  anaesthetic;  if  so,  it  is  functional  (see  Hysteria). 


Fig.  18.— The  Haxd  in  Athetosis  (Strumpell). 

In  forced  movements  the  patient  suddenly  and  involuntarily 
is  thrown  forward,  sideways,  or  whirled  about  in  various  ways. 

Associated  move?nents  are  those  which  occur  involuntarily  in 
a  limb  or  muscle  at  rest  when  the  corresponding  limb  or  muscle 
is  moved  on  the  opposite  side. 

Thus  in  hemiplegia  the  movement  of  the  normal  arm  may  ex- 
cite a  movement  in  the  one  paralyzed.  The  patient  is  given 
a  piece  of  chalk  in  each  hand,  and  each  hand  is  placed  upon  a 
blackboard  lying  on  the  table;  attempts  at  drawing  lines  with 
the  sound  arm  cause  movements  of  a  similar  kind,  but  less  per- 
fect, on  the  paralyzed  side. 

Paralysis  or  akinesis  is  a  loss  of  motor  power.  Monoplegia  is 
a  condition  in  which  one  limb  is  paralyzed ;  hemiplegia  one  in 
which  one-half  the  body  is  paralyzed ;  and  paraplegia  one  in  which 
the  tAvo  lower  limbs  are  affected.  Sometimes  a  double  hemiplegia 
or  diplegia  occurs. 

The  term  parpdysis  is  sometimes  used  to  indicate  loss  of  any 
kind  of  function,  as  jiaralysis  of  sensation  or  secretion. 

Paresis  is  a  term  used  to  indicate  a  partial  paralysis.     It  is  not 


20 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


to  be  confoiindtHl  with  the  term  ^'eneral  paresis,  which  is  a  form 
of  insanity. 

77/e  RtJh.V(s  and  Th<ir  Disorders.— \^\\en  an  impulse  started 
in  an  afferent  nerve  reaches  the  spinal  cord  or  medulla  and  is 
thence  reflected  at  once  upon  an  efferent  nerve,  it  is  called  a  sim- 
ple rtflt.v  action.  The  process  is  an  involuntary  one.  It  ordi- 
narily occupies  one-tenth  to  one-twelfth  of  a  second.-  The  affer- 
ent nerve  may  be  an  ordinary  cutaneous  sensory  nerv^e,  or  it 
may  be  a  special  nerve  whose  sole  function  is  to  excite  reflex 
action.  These  latter  nerves  are  called  excito-reflex.  This  kind 
is  principally  supplied  to  the  viscera. 


Fig.  19.— Diagram  showing  the  Reflex  Arc  of  Spinal  Cord.    S,  Sensory  excitx>- 
reflex  nerves;  4,  motor  nerve  to  muscle;  5,  motor  nerve  cell. 


In  neurology  we  have  to  do  with  four  kinds  of  reflexes: 

The  skin  or  superficial  reflexes. 

The  tendonous  or  deep  reflexes. 

The  visceral  reflexes. 

Idiopathic  muscle  reflex. 

All  these  may  be  exaggerated,  lessened,  or  absent.  Further 
description  of  these  reflexes  will  be  given  under  the  head  of  diag- 
nosis. 

3.  Sensor)/  symptom.s: 

Amrathesia  is  a  loss  of  tactile  sensibility. 

Analgesia,  a  loss  of  sensibility  to  pain. 

Thermo-anasthesia,  a  loss  of  sensibility  to  temperature.  There 
may  be  loss  of  cold-sense  or  of  heat-sense,  or,  as  is  usually  the 
case,  of  both  sen.ses.  , 

The  term  aiuesthesia  is  often  used  with  a  general  meaning  to 


GENERAL   DESCRIPTION   OF   NERVOUS   DISEASES.        21 

indicate  loss  of  all  forms  of  sensibility.  Antesthesia  in  this  sense  is 
a  symptom  referred  to  the  skin,  bones,  mucous  membranes,  special 
senses,  or  viscera.  The  muscles  have  two  kinds  of  sensibility,  a 
sensibility  to  pain  and  a  special  muscle  sense.  Anaesthesia  of  the 
pain  sense  of  muscle  is  called  loss  of  muscular  sensibility  or  mus- 
cular analgesia.  Anaesthesia  of  the  special  muscle  sense  is  one 
of  the  factors  in  causing  a  symptom  known  as  ataxia. 

Ataxia  is  a  symptom  due  to  loss  of  the  special  sensibility  of 
the  muscles,  articular  surfaces,  and  tendons.  This  special  sense 
informs  the  individual  of  the  degree  and  strength  of  muscular 
movements,  and  by  it  definite  and  co-ordinated  movements  are 
made  possible.  The  weight  of  objects  and  position  of  the  limbs 
are  also  determined  by  it. 

In  static  ataxia  there  is  loss  of  the  power  to  preserve  perfectly 
the  equilibrium  when  standing.  It  is  due  to  the  form  of  anaes- 
thesia just  referred  to. 

In  locomotor  or  motor  ataxia  there  is  loss  of  power  to  co-ordi- 
nate the  limbs  properly  in  motion.  In  these  conditions  there  is 
also  usually  a  loss  of  power  to  appreciate  weights  or  the  position 
of  the  limbs.  The  term  muscular  ana'sthesia,  however,  is  often 
used  to  indicate  these  latter  symptoms. 

Cerebellar  ataxia  is  a  form  of  inco-ordination  due  to  disease 
of  the  central  organ  of  equilibration,  viz.,  the  cerebellum. 

The  anaesthesias  may  be  incomplete,  and  special  technical 
terms  are  sometimes  used  to  indicate  such  conditions,  but  they 
are  not  necessary. 

Hi/jyera'sthesia  is  an  excessive  sensibility  to  touch,  contact,  and 
other  stimuli. 

Hyperalgesia  is  excessive  sensibility  to  pain,  and  is  nearly 
identical  Avith  tenderness. 

Dyscesthesia  is  an  abnormal  sensation  such  as  a  "thrill"  or 
feeling  of  discomfort  produced  by  ordinary  tactile  or  painful  im- 
pressions. 

Paresthesia  is  a  term  applied  to  all  the  morbid  general  sensa- 
tions except  pain.  The  paraesthesias  include  such  feelings  as 
numbness,  prickling,  formication,  flushing,  burning,  itching,  cold- 
ness, tickling,  feelings  of  weariness,  exhaustion,  various  peculiar 
visceral  sensations.  Ordinarily  in  speaking  of  paraesthesiae, 
however,  we  refer  to  such  feelings  as  numbness,  prickling,  and 
creeping. 

Delayed  sensation  is  a  symptom  in  which  an  appreciable  time 
exists,  usually  one  or  more  seconds,  between  the  time  of  applying 
a  stimulus  and  its  appreciation  in  consciousness.  Normally  a 
tactile  sensation  can  be  felt  and  responded  to  in  less  than  one- 
tenth  of  a  second. 

Transferred  or  referred  or  reflex  sensations  are  those  in  which 


2'Z  DISEASES   OF  THE   NERVOUS   SYSTEM. 

the  irritation  is  iiuule  at  one  point  and  felt  at  another.  Thus  an 
irritation  in  tlie  stomach  causes  a  pain  felt  in  the  forehead. 
The  wliole  class  of  so-called  reflex  pains  are  realh-  transferred 
sensiitions,  since  in  reality  there  is  no  reflex  action  in  the  process, 
as  will  be  seen  later.  AUochiria  is  a  peculiar  form  of  transferred 
sensation  in  which  an  irritation  applied  on  one  side  of  the  body- 
is  referred  to  a  corresponding?  point  on  the  opposite  side. 

The  special  senses  when  disordered  cause  symptoms  which  are 
given  special  names.  These  will  be  described  in  connection  with 
the  si)ecial  subjects. 

4.  Troph  id  Bisorde rs.— These  are  called  tropho-neuroses.  They 
consist,  so  far  as  relates  to  neurology,  chiefly  of  hypertrophy 
and  atrophy  of  nerves,  muscle,  cutaneous  and  mucous  tissues, 
joint  degenerations,  and  various  skin  erui^tions. 

The  tropho-neuroses,  if  they  afTect  joints,  are  called  arthro- 
pathies; if  muscles,  atrophies,  hypertrophies,  and  dystrophies;  or 
if  with  atrophy  there  is  a  great  substitution  of  fat  the  condition  is 
known  as  lipomatosis.  When  nerves  are  affected  there  results  de- 
generation. 

Tropho-neuroses  of  the  skin  produce  various  symptoms  such 
as  herpes,  pemphigus,  and  other  eruptions,  pigmentation,  leuco- 
derma,  alopecia,  and  bed-sores. 

5.  Vd.somotor  and  ^ecretorij  St/mj^foms. — The  nerves  supplying 
the  blood-vessels  and  secreting  glands  work  together  and  are 
usually  disordered  together.  Separate  disturbances  of  the  ves- 
sels and  glands,  however,  occur. 

AuQW-neurosis  is  the  term  given  to  disorders  of  the  vaso- 
motor centre  and  nerves.  Angiospasm  is  a  condition  in  which 
there  is  increase  of  vasomotor  tone  and  spasmodic  contraction  of 
the  muscular  coats  of  the  arteries.  Angio-jyaralysis  represents 
the  oi)p<)site  condition.  Such  disorders  affecting  the  skin  are 
shown  by  pallor  and  coolness  or  by  flushing  and  heat.  Angio- 
ataxia  is  a  condition  of  variability  and  irregularity  in  the  tonus 
of  the  blood-vessels. 

C).  The  secretory  neuroses  affect  oftenest  the  skin. 

Hyperidrosis  is  an  excessive  sweating.  Anidrosis  is  excessive 
dryness.  Paridrosis  is  a  perversion  of  secretion  in  which  peculiar 
odors  or  colors  are  noted.  Hainidrosis  is  the  term,  applied  to 
bloody  sweating. 

The  secretions  of  the  internal  organs  are  controlled  by  ner- 
vous influences,  but  their  si)ecial  disturbances  do  not  require  de- 
scription here. 


CHAPTER   III. 

DIAGNOSIS   AND   METHODS   OF  EXAMINATION. 

The  diagnosis  of  a  nervous  disease  may  be  simply  a  clinical 
one;  that  is  to  say,  one  may  recognize  it  as  belonging  to  a  certain 
known  and  definite  group  of  symptoms.  Thus  in  recognizing  the 
phenomena  of  epilepsy,  one  makes  a  clinical  diagnosis.  In  other 
cases,  and  especially  in  all  organic  nervous  diseases,  the  physician 
must  make  in  addition  a  local,  and  then  a  jjathological  diagnosis. 
That  is,  we  must  determine  the  seat  and  nature  of  the  disease. 

A  diagnosis  is  made  by  first  getting  all  the  obtainable  facts  in 
the  i^atient's  past  history,  then  by  learning  from  him  all  his  sub- 
jective symptoms,  and  finally  by  making  an  examination  accord- 
ing to  the  technical  methods  to  be  here  described.  In  examining 
a  patient,  it  is  imperative  that  a  careful  search  for  diseases  out- 
side the  nervous  system  first  be  undertaken.  Then  the  morbid 
nervous  phenomena  should  be  investigated.  The  physician  should 
make  it  an  invariable  rule  to  make  this  examination  in  a  certain 
fixed  and  systematic  manner.  The  best  method  is  first  to  get  the 
family  and  personal  history,  and  then  to  go  over  the  mental,  cere- 
bral, and  special  nervous  functions  serially  in  the  way  indicated 
under  the  description  of  general  symptoms,  thus :  Examine — 

1.  Physiognomy,  general  condition  of  nutrition,  complexion, 
physical  defects  (stigmata  of  degeneration),  gait,  station,  i^os- 
ture,  speech. 

2.  Mental  and  cerebral  symptoms. 

3.  Motor  and  muscular  symptoms,  including  muscular  and 
joint  atrophies,  electrical  reactions,  and  the  reflexes. 

4.  Sensory  symptoms,  general  and  special. 

5.  Vasomotor,  troiDhic  and  secretory. 

6.  Visceral  centres. 

In  investigating  the  family  history,  it  is  often  necessary  to 
make  very  direct  and  probing  inquiries,  for  patients  are,  as  a 
rule,  inclined  to  forget  or  ignore  the  existence  of  nervous  and 
mental  disease  among  relatives.  The  existence  of  consumption 
and  inebriety,  epilepsy  and  syphilis,  in  the  direct  line  are  very 
important  facts;  so  also  are  those  concerning  birth.  The  pa- 
tient should  be  questioned  closely  as  to  his  previous  diseases, 
especially  syphilis;  also  as  to  his  habits  in  relation  to  sexual 
indulgence,    indulgence   in    alcohol,    and   smoking.     In  women, 


24  DISEASES   OF  THE   NEKVOUS   SYSTEM. 

the  tea  ha])it  should  be  inquired  into.  The  patient  may  be  al- 
lowed to  tell  his  own  story  first.  Proper  queries  should  be  put  to 
supplement  this,  and  tinally  the  patient  should  be  asked  to  state 
those  symptoms  which  to  his  mind  are  main  and  dominant. 

"NVe  will  now  go  over  the  above  points  in  detail. 

I.  The  physiognomy,  complexion,  posture,  and  gait  being 
noted,  the  physician  looks  next  for  evidences  of  imperfect  physi- 
cal development.  These  are  known  as  the  stigmata  or  marks  of 
degeneration. 

Marks  of  Degeneration.— (reweraZ.— Shortness  of  height, 
general  feebleness  of  constitution. 

Left  arm  and  leg  larger  than  right,  long  fingers. 

Cranial. — Asymmetry  of  skull,  and  especially  of  frontal  bone. 

Short  parietal  arc  (noted  in  epilepsy),  short  "frontal  arc  (noted 
in  petit  mal). 

Peculiar  type  of  skull,  e.g.,  trigonal,  seai:)hocephalic,  plagio- 
cephaiic. 

High,  prominent  forehead  in  women. 

Heavy  jaws,  lemurian  hyxDophesis,  prognathism. 

Large  frontal  sinuses,  small  orbit. 

High  and  narrow  palate  (noted  in  idiots). 

Muscular. — Unequal  innervation  of  facial  muscles  on  the  two 
sides. 

Depression  above  glabella  due  to  over-action  of  corrugators 
(noted  in  epilepsy). 

Squints  and  astigmatism. 

Ottier  J/rt;-A' 6*.— Deviation  of  nose;  ears  long,  or  prominent,  or 
set  too  far  back ;  absence  of  helix,  anti-helix,  or  lobule. 

Badly  set  and  badly  nourished  teeth. 

Crown  of  scalp  double  or  out  of  place. 

Small  or  deformed  genitals,  atrophic  uterus. 

Physiological  marks  are  those  of  deficient  vital  activity  of  the 
organic  functions,  such  as  weak  heart,  low  arterial  tension,  un- 
stable vasomotor  innervation  causing  coldness  and  flushing  of 
extremities,  weak  digestion,  constipation,  amenorrhoea,  sexual 
weakness  or  perversion. 

Psychical  marks  are  those  in  general  of  feeble  or  erratic 
mental  activity,  unstable  will,  deficient  moral  sense,  and  lack  of 
emotional  control. 

"While  many  of  the  foregoing  stigmata  have  no  significance  in 
themselves,  yet  a  combination  such  as  impresses  the  observer 
with  its  preponderance  is  of  great  importance,  for  neuroses  or 
psychoses  developed  among  this  class  have  a  much  more  unfavor- 
able prognosis.  It  is  especially  among  neurasthenics,  epileptics, 
severe  forms  of  hysteria,  and  in  the  insanities  that  these  signs  are 
to  be  looked  for  and  studied.  Among  normal  men  about  two  per 
cent  have  the  stigmata  of  degeneration;  among  lunatics,  crimi- 
nals, abortive  types  of  paranoia  and  primary  forms  of  neuras- 
thenia, the  percentage  is  about  thirty. 

The  accompanying  talile  will  be  of  help  in  making  the  in- 
vestigations relating  to  the  cranium : 


DIAGNOSIS  AND   METHODS   OF  EXAMINATION. 


25 


Taken  around  glabel- 
la and  maximal  oc- 
cipital noint. 

Measured  from  b  over 
through  bregma  to 
6,    or   opposite  ext. 
and.  meatus. 

j  Benedict  and 
1  Hu.schke. 

fi  to  a. 
a  to  t. 

From  n  to  lowest  point 
of  chin. 

The  empirical  greatest 
heigiit,  b  p,  is  ob- 
tainetl  by  measuring 
the  sides  of  the  tri- 
angle in  /3  t. 

•JvCq^si 

jopua 

1    :    s 

•SJBaX 
o?  qwi 

^?4    ; 

q48l 
Oi  q;^ 

>> 

fe 

f- 

•  1?    :   : 

S 

§                     1    :  :-  i 

I- 

2 

fe  1      :       %^ 

'1    i         ^ 

1 

^  1    ^'       t1 

O  OO     ■ 

M. 

42.0 
''.5  5 

700  to  1,000 
28.0 

F. 
84.0 
20.0 

22.0 

7.7 
9.0 

M. 
84.0 
20.0 

885  to  4.50 
22.0 

9^0 

Physiological 
Variation. 

48.5  to  57.4 

28.4  to  35  0 

1,201  to  1,751 

28' to  88 
10.9  to  14.9 
9.1  to  14.4 

](*..5tol9.0 
13  to  1G.5 

70.1  to  87 

10.5  to  14.4 

11.5  to  15 
70.0  to  74.9 
75.0  to  79.9 
80.0  to  84.9 
over  loo  to  1.50 

t 
[B 

^ 

^ 

50.0 
81.0 

1,800 

31.0 
12.0 
11.9 
7.1 

17.2 

14.0 

83.8 

12.3 

s" 

52.0 
82.0 

1,500 

32.0 
12.5 
12.5 
7.0 

17.7 

14.G 

82.2 
12.37 

13.3 

1.  Greatest  circumfer- 

ence   

2.  Binauriculararc. . . 

3.  Volume 

4.  Naso-occipital  arc. . 

5.  Naso-bregmatic  arc 
G.  Bregmat.  lamb,  arc 

7.  Lamb,  occipital  arc 

8.  A  n  t  e  r  o  -  posterior 

diameter  

9.  Greatest  transverse 

(Uaiiifter 

10.  Cephalic  or  length- 
brtadlh  index 

12.  Facial  length 

13.  Empirical  greatest 

llri^lit 

Dolichuccnhalv 

> 

X 

5s 

26 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


To  nndorstanil  it,  it  is  necessary  to  descriV)e  the  skull  land- 
marks, and  to  ^'ive  V)rietly  the  classification  and  terms  used  by 
anthropolot^ists  and  alienists  in  describinjj  the  dimensions  and 
shape  of  the  skull. 

Dimensions  and  Shape  of  ^kvIjI^.— General  Classification. 
—Anthropologists  make  a  general  classification  of  skulls  into — 

Tl)e  dolichocephalic,  in'  which  the  antero-posterior  diameter 
is  to  the  transverse  as  100  is  to  75  or  less;  the  brachycephalic, 
in  Mhicli  the  length  is  to  the  breadth  as  100  is  to  80  or  more; 
the  mesocephalic,  in  which  the  length  is  to  the  breadth  as  100  is 
to  75  to  bO.  The  physiological  limits  of  variation  in  the  ratio  of 
length  to  breadth  are  from  100  to  70  to  100  to  90.  The  dimensions 
and  shape  of  the  skull  vary  with  age,  sex,  individual,  race,  and 
with  certain  pathological  conditions  and  artificial  deformities. 
In  general,  liowever,  the  variations  in  the  shape  and  size  of  the 


Fig.  eo.— B,B,  Broca's  visual  plane;  vi.^.t,  the  triangle  for  ascertaining  the 
empirical  greatest  height  (Benedict). 

skulls  of  healthy  adults  of  European  and  American  races  are 
fairly  uniform. 

Variations  Df^peuflent  upon  Age.— The  proportions  of  the  skull 
change  most  considerably  in  the  first  year,  and  continue  to 
change  up  to  the  fourth  year.  After  that,  modifications  are 
slight  in  amount  and  appear  more  slowly.  Bv  the  end  of  the 
seventh  year  the  skull  has  nearly  reached  'its  full  size  (see  table), 
inore  nearly  in  girls  than  in  boys.  The  chief  measurements  dur- 
ing childhood  are  given  in  tlie  table.  The  protuberances  and 
ridges  are  less  marked  in  children. 

The  female  shall  is  larger  posteriorly,  is  broader,  lower,  with 
higher  orbital  diameter;  often  it  has  no'glabella,  no  super-glabel- 
lar  depression,  and  is  less  well  marked  as  to  its  ridges,  promi- 
nences, and  sutures. 

Variations  as  Beejards  Race.—The  length -breadth  index  and 
other  cranial  indices  and  the  volume  are  the  only  racial  differ- 
ences so  far  extensively  studied.  Even  these  are^too  indefinite 
factors  to  be  of  any  practical  value.     In  general,  we  may  say  that 


DIAGNOSIS   AND   METHODS   OF   EXAMINATION.  27 

the  dolichooephalic  or  long:-lieaded  are:  the  Eng:h.sh,  Irish,  Scan- 
dinavians, negroes,  73;  Arabs,  74;  Chinese,  70.  The  brachyceph- 
aUc  or  broad-headed  are :  the  e-rernians,  Si ;  Russians,  Turks,  81. 
The  mesooephahc  or  medium-shaped  heads  are :  the  American  In- 
dians, 79;  Hollanders,  Parisians,  71). 

The  Variations  Depeyident  upon  Artificial  Deformities,  Acci- 
dents, Fercersions  of  Growth  and  Development,  and  upon  Dis- 
ease.— There  ai-e  certain  more  or  less  jjathological  variations 
in  the  shape  of  the  skull,  due  to  a  premature  ossification  of  a 
suture,  or  arrest  of  development  in  a  centre  of  ossification,  or  to 
a  hyperplasia,  or  aplasia  of  a  part  of  the  skull  or  of  its  contents. 
When  one  part  is  shut  off  from  its  natural  expansion,  other  parts, 
as  a  rule,  undergo  compensatory  development.  This  principle 
underlies  the  pathology  of  cranial  deformities.  Those  deformitiof! 
Avhieh  it  would  be  well  to  look  for  are — 

The  triangular  or  trigonocephalic  skull.  The  keel-shaped  or 
scaphocephalic  skull.  The  acrocephalic  skull.  The  oxycephalic 
or  steeple-shaped  skull.  The  flat-headed  skull.  The  plagioceph- 
alic  or  obliquely  deformed  skull. 

Variations  in  the  Insane,  Criminal,  Epileptic,  and  other  Psy- 
chopathic Classes  Generally. — Minimal  measurements  of  the  fron- 
tal arc  {n  ji)  are  oftener  found  in  insane  and  criminals.  The  pa- 
rietal arc  is  also  said  to  be  often  shorter  in  the  insane,  defective, 
and  delinquent  classes  and  in  epileptics.  In  these  classes,  how- 
ever, maximal  excesses  also  often  occur. 

There  is,  as  yet,  no  acknowledged  special  variation  or  type 
which  is,  of  itself,  an  indication  of  a  peculiar  mental  trait  or  spe- 
cific pathological  condition,  although  Lombrosoand  his  followers 
have  tried  to  make  out  such.  On  the  whole,  it  is  found  that  pro- 
nounced deformities  occur  often  in  healthy  j^ersons,  while  in  psy- 
chopathic classes  and  cnminals  there  is  a  large  proportion  of 
slight  variations  generally  minimal,  i.e.,  below  the  mean  meas- 
urements from  the  normal  type. 

For  all  ordinary  purpose's  the  only  instruments  needed  in  ex- 
amining the  cranium  are  a  tape,  a  strip  of  lead  to  use  as  a  con- 
form ateur,  and  a  pelvimeter. 

2.    IXYESTIGATIOX  OF  SYMPTOMS  OF  DISORDERED  MOTILITY. 

— The  recognition  of  gross  disturbances  such  as  hemiplegia  and 
paraplegia  is  easy.  To  determine  the  exact  extent  of  the  paral- 
ysis, the  patient  must  be  made  to  move  the  limbs  and  contract 
the  muscles  in  every  possible  way.  The  degree  of  paralysis  in 
some  groups  of  muscles  can  be  measured  by  dynamometers. 
The  ordinary  hand  dynamometer  of  Mathieu  measures  the 
degree  of  paralysis  in  the  flexors.  It  should  be  graduated  accu- 
rately in  pounds  or  kilograms.  I  have  devised  an  instrument  by 
which  the  strength  of  the  extensors  of  the  hand  and  fingers  can 
be  tested. 

The  average  power  of  pressure  on  the  Mathieu  dynamometer 
is,  for  an  adult,  forty  to  fifty  kilograms  for  the  right  hand,  and 
three  to  five  kilograms  less  for  the  left.  A  woman  has  about 
two-thirds  of  the  power  of  a  man. 

I  have  had  constructed  an  apparatus  by  which  the  strength 
of  the  leg-push,  i.e.,  of  the  extensors  of  the  leg,  and  foot  and  the 


28 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


extensors  of  the  thifxh  is  tested.  The  anterior  tibial  and  calf  mus- 
cles can  also  be  tested  by  means  of  an  instrument  called  the  pe- 
dometer devised  by  the  late  Dr.  William  R.  Birdsall.  A  good  idea 
of  the  degree  of  paralysis  can  be  got  by  making  the  patient  take 
the  x^hysician's  two  hands  with  his  own  and  squeeze  each  at  the 
same  time.  A  malingerer  or  hysteric  will  often  in 
this  way  unconsciously  press  much  harder  than  he 
is  aware.  The  physician's  own  ingenuity  will  sug- 
gest various  ways  of  testing  the  strength  of  the  leg 
and  thigh  muscles,  such  as  making  the  patient  rise 
on  one  toe,  climb  upon  a  chair,  push 
against  an  object  M'itli  his  foot.  etc. 


Fig.  21.— Leg  Dynamometer. 


Fig.  •2-2.— Foot  Dynamometer. 


Tremor  is  tested  by  making  the  patient  hold  out  the  hands 
and  arms  at  full  length,  spreading  out  the  fingers  at  the  same 
time.  To  determine  whether  the  tremor  increases  on  volitional 
movement,  give  the  patient  a  full  glass  of  water,  let  him  hold  it 
out  for  a  moment,  then  bring  it  to  his  mouth  slowly.     If  the 


^v-^)(yi^,A^AM^AJy^^'^HVAAA^ 


iHHHHHmmmmHmimmmtmmmHmmmmHmmmmmmHmmmwmmmmmm, 

smovd 


Fig.  23. 


-Diagram  of  a  Fine  Vibratory  Tremor.    Ten  of  the  divisions  on  the 
lower  line  equal  a  second. 


tremor  increases  with  this  movement  it  is  called  "  intentional." 
As  a  general  rule,  the  tremor  of  organic  disease  is  increased  by 
volitional  movement,  and  ceases  during  rest  of  the  extremity. 
Functional  tremors  are  usually  continuous. 

In  some  forms  of  tremor  the  hand   and  arm  shake  as  a  whole ; 
such  tremors  are  called  vi])r;itorv.     In  other  forms  the  tremor  in- 


DIAGNOSIS   AND   METHODS   OF   EXAMINATION.  29 

volves  only  the  fingers  or  hand.  Such  tremors  are  called  oscilla- 
tory or  segmental. 

The  apparent  vibration  of  a  tremor  may  range  from  five  or  six 
to  ten  or  twelve  per  second.  To  determine  accurately  whether 
the  tremor  is  fine  oy coarse  special  apparatus  is  needed;  but  one 
can  with  a  little  experience  determine  this  fairly  well  by  observa- 
tion alone.  Or  we  can  use  a  sphygmograph  as  shown  by  Dr.  F. 
Peterson.  This  instrument  is  fixed  firmly  on  the  table,  and  the 
tremulous  forefinger  held  lightly  against  the  lever.  Tremor  that 
is  hardly  observable  by  the  eye  can  be  felt  by  placing  one's  hand 
against  the  extended  fingers  of  the  patient.  Tremor  of  the  tongue 
and  lips  and  facial  muscles  must  be  carefully  looked  for.  It  is 
tested  by  making  the  patient  close  the  eyes  tightly  and  show  the 
teeth  or  protrude  the  tongue.  Tremor  of  the  whole  head  due  to 
the  neck  muscles  must  be  distinguished  from  secondary  shaking 
of  the  head  due  to  a  tremor  of  the  trunk. 

Fihrillanj  tremor,  which  involves  only  certain  fibres  of  the 
muscle,  is  seen  oftenest  in  the  tongue  and  face  muscles  of  the 
extremities. 

Choreic  movements,  tics,  associated  and  forced  movements, 
and  the  other  forms  of  motor  disturbance  can  be  recognized  by 
simple  observation. 

Myoidema  is  a  tonic  spasm  of  a  part  of  a  muscle  near  its  ten- 
donous  attachment.  It  is  produced  by  a  sharp  blow  upon  the 
muscle  near  its  tendonous  insertion.  This  causes  the  umscular 
fibres  to  bunch  up  into  a  small  tumor  for  several  seconds.  Its  pres- 
ence indicates  rapid  muscular  wasting  from  exhausting  disease. 

Idiopathic  muscular  spasm  is  a  phenomenon  of  a  similar  na- 
ture. When  the  belly  of  a  muscle  is  struck  with  a  dull  instru- 
ment, a  welt  of  contracted  muscle  appears  and  lasts  several  sec- 
onds.    It  indicates  an  exaggerated  muscular  irritability. 

The  Examination  of  the  Reflexes.— These,  as  already 
stated,  are  of  four  kinds :  (1)  the  su^^erficial  or  skin,  (2)  the  deep 
or  tendonous,  (3)  the  visceral,  and  (4)  the  muscle  reflexes. 

1.  A  skin  or  superficial  refiex  is  produced  by  scratching,  tick- 
ling, pinching,  or  irritating  the  skin,  with  hot,  cold,  or  chemical 
irritants.  The  result  is  a  contraction  of  the  muscles  supplying 
the  parts  near  the  irritation.  The  skin  reflexes  which  can  be  or- 
dinarily brought  out  are  the  plantar,  cremasteric,  epigastric,  ab- 
dominal, erector  spinal,  interscapular,  palmar,  and  certain  cranial 
reflexes. 

The  plantar  reflex  is  produced  by  tickling  or  scratching  the 
soles  of  the  feet.  This  causes  a  quick,  involuntary  jerking  up  of 
the  foot  and  leg. 

The  cremasteric  reflex  is  brought  out  by  scratching  the  inner 
side  of  the  thigh  or  the  skin  over  Scarpa's  triangle.  It  causes  a 
drawing  up  of  the  testicle  on  the  same  side. 


30 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  abdominal  reflex  consists  of  a  contraction  of  the  abdomi- 
nal muscles,  caused  by  irritating  the  side  of  the  abdomen. 

The  epigastric  reflex  consists  of  a  contraction  of  the  upper 
fibres  of  the  rectus,  caused  by  irritating  the  skin  of  the  lower  part 
and  side  of  the  thorax. 

The  erector-spinccl  reflex  consists  of  a  contraction  of  some  of 
the  fibres  of  the  erector  spincel,  caused  by  irritating  the  skin  along 
its  outer  edge. 

The  scapular  reflex  consists  of  a  contraction  of  some  of  the 
scapular  muscles,  caused  byirritating  the  skin  over  them. 

The  palmar  reflex  is  produced  by  irritating  the  palms  of  the 
hands. 

The  cranial  reflexes  are  the  lid  reflex,  caused  by  irritations  of 
the  conjunctiva  or  of  the  retina:  the  pupillary-skin  reflex,  which 
consists  of  a  dilatation  of  the  pupil  caused  by  scratching  the  skin 
of  the  cheek  or  chin. 

The  levels  of  the  spinal  cord  through  which  the  impulse  travels 
are  indicated  in  the  accompanying  table : 

Table  showi:s'g  the  Nerves   axd    Spixal   Cord  Levels 


Brought   ixto 
Reflexes. 


Play   ix    the    Different    Superficial 


Spinal 
Nerve. 

1 

2 
3 


Superficial 
Reflex. 


61 


8capul; 


Spinal 
Nerve. 

81 

I 

01 

I 

.  10  I 

^         V 

i"l 

12  I 
J 

n 
I 

I  4) 
5*  J 

1 


Superficial 
Reflex. 


Abdominal 


Cremasteric 


Kfiee  jerk 
^      Gluteal 
r  Ankle  clonus 


41 


5   ^ 


Epigastric      E 


Plantar 


DIAGNOSIS   AND   METHODS   OF   EXAMINATION.  31 

The  superficial  reflexes  that  can  ordinarily  be  brought  out  in 
healthy  persons  are  the  plantar,  cremasteric,  epigastric,  and  the 
cranial  reflexes.  The  palmar  reflex  is  rarely  i^resent  in  healthy 
people  except  during  sleep,  and  in  children.  The  superficial  re- 
flexes depend  upon  the  integrity  of  the  reflex  spinal  arc,  and  to  a 
less  extent  upon  the  degree  of  cerebral  inhibition.  When  present, 
they  show  that  the  spinal  cord  at  the  level  through  which  the 
impulses  travel  is  healthy.  When  absent,  they  do  not  necessarily 
Indicate  much  of  anything.  For  they  vary  in  amount  in  differ- 
ent persons  and  at  different  ages.  In  cerebral  hemiplegia  during 
and  for  a  time  after  the  acute  attack,  they  are  generally  lessened 
or  absent  on  the  affected  side.     Later  they  may  be  exaggerated. 

The  deep  reflexes  are  sometimes  called  tendon  reflexes.  They 
are  brought  out  by  striking  a  stretched  tendon  or  muscle  or  even 
by  tapping  a  bone  or  striking  the  muscular  fascia.  The  deep  re- 
flex in  these  cases  is  probably  a  true  spinal  reflex,  though  some 
assert  that  it  is  due  to  the  direct  effect  of  the  concussion  or  sud- 
den stretching  upon  the  muscle  itself  (Gowers),  which  is  m  a 
condition  of  slight  tonus.  Either  view  involves  the  integrity  of  a 
reflex  arc. 

The  deep  reflexes  are — 

The  patella-tendon  reflex  or  knee  jerk.  The  ankle  reflex  or 
ankle  clonus.  The  wrist  reflex.  The  triceps-tendon  reflex  or  el- 
bow jerk.  The  jaw  reflex  or  chin  jerk.  The  light  (or  pupillary) 
and  accommodation  (or  ciliary)  reflexes. 

The  x>(^teUa  reflex  or  knee  jerk  consists  of  a  sudden  contraction 
of  the  quadruceps  femoris,  vastus  internus,  and  subcrureus  caused 
by  striking  the  patella  tendon  when  the  leg  hangs  loosely  at 
right  angles  with  the  thigh.  This  reflex  may  also  often  be  pro- 
duced by  striking  the  lower  part  of  the  muscle  itself.  The  ac- 
tivity of  this  reflex  is  increased  if,  at  the  same  time  that  the  blow 
is  struck,  a  voluntary  contraction  of  some  other  muscles  is  made 
by  the  patient.  Usually  the  patient  is  told  to  pull  on  his  clasped 
fingers,  or  tightly  shut  the  hands.  This  process  is  called  the  re- 
enforcement  of  the  knee  jerk  (see  Fig.  24). 

The  knee  jerk  is  present  practically  in  all  healthy  persons  ex- 
cept the  aged.  Its  absence  is  always  of  significance.  The  nerve 
roots  involved  are  those,  in  man,  of  the  fourth  lumbar  pair.  The 
peripheral  nerve  is  the  anterior  crural.  The  most  essential  mus- 
cle is  the  vastus  internus  (Sherrington). 

Ankle  clonus  is  caused  by  having  the  seated  patient  extend 
the  limb  and  hold  it  rather  firmly  in  a  semi-flexed  condition. 
The  physician  takes  the  foot  by  the  toe  and  heel  and  quickly 
flexes  the  foot  on  the  leg.  He  thus  suddenly  stretches  the  calf 
muscles,  and  they  undergo  rhythmical  contraction.  This  phe- 
nomenon does  not  occur  in  healthy  people.     An  ankle-tendon  re- 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


flex,  however,  is  brought  out  in  normal  conditions  Ijy  striking  the 
Achilles  tendon  when  the  foot  is  held  slightly  flexed  by  the  phy- 
sician. 


if m f^"^  -  r 


FiQ.  24.— Getting  the  Knee  Jerk  by  Re-enforcement. 


DIAGNOSIS   AND   METHODS   OF  EXAMINATION. 


33 


The  "  paradoxical  contraction  "  is  a  name  given  to  the  tonic 
contraction  of  the  anterior  tibial  muscles  caused  by  the  physi- 
cian's suddenly  flexing  the  foot  on  the  leg,  thus  shortening 
these  muscles.  This  is  a  rare  phenomenon  and  never  found  in 
health.  The  wrist  reflex  is  brought  out  by  striking  the  wrist 
tendons  while  the  forearm  is  supinated  and  held  limply  on  the 
hand  of  the  physician.  The  triceps  reflex  or  elbow  jerk  is 
brought  out  by  striking  the  triceps  tendon  while  the  arm  is  sup- 


FiG.  35.— Getting  the  Elbow  Jerk. 


ported  and  the  forearm  allowed  to  hang  down  loosely  at  right 
angles  to  the  arm.  These  reflexes  occur  in  normal  individuals. 
The  jaw  reflex  or  jaw  jerk  is  brought  out  by  having  the  patient 
open  the  mouth  and  leave  the  jaw  relaxed.  A  flat  instrument 
like  a  paper  cutter  is  then  laid  on  the  teeth  of  the  lower  jaw, 
and  if  this  is  struck  smartly  the  elevators  of  the  jaw  contract. 

The  light  reflex  is  caused  by  throwing  a  bright  light  into  the 
eye,  and  the  ciliary  or  acconnnodation  reflex  by  making  the  pa- 
tient look  at  a  distant  and  then  at  a  near  object.     The  pupil 
3 


34 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


normally  dilates  in  the  former  case  and  contracts  in  the  latter. 
When  the  light  reflex  is  lost  while  the  accommodation  reflex  re- 
mains, the  condition  is  called  the  Argyll- Robertson  pupil. 

The  deep  reflexes  which  do  not  occur 
in  healthy  individuals  are:  ankle  clonus, 
paradoxical  contraction,  jaw  clonus,  and 
usually  the  wrist  reflex.  The  deep  reflexes 
may  be  brought  out  by  simply  striking 
the  tendon  with  the  side  of  the  hand  or 
the  back  of  a  book.  For  careful  work,  a 
percussion  hammer  is  very  useful. 


Fig.  26.— Getting  Ankle  Clonl's. 


The  Electrical  Conditions  in  Bisturhances  of  Motility. — These 
cannot  be  understood  without  some  description  of  the  methods 
of  using  electricity,  and  hence  the  technique  of  electrical  exami- 
nations for  purposes  of  diagnosis  will  be  described  under  the  head 
of  Treatment. 

3.    EXAMIXATIOX     OF     THE     DISORDERS     OF    SeNSATIOX.— It 

should  be  remembered  that  sensations  are  of  two  kinds,  general 
or  common  and  special. 

A  common  sensation  is  one  which  is  referred  to  the  body.  A 
special  sensation  is  one  which  is  referred  to  the  external  world, 
and  in  particular  to  the  object  which  causes  the  stimulus.  The 
I^ain  from  a  knife  cut  is  referred  to  the  body,  and  is  a  common 
sensation.  The  coldness  felt  when  a  knife  blade  is  laid  on  the 
skin  is  referred  to  the  knife,  and  is  a  special  sensation. 

The  sensory  functions  to  be  examined  are : 

The  cutaneous. 

The  muscular,  articular,  and  tendonous. 

The  visual,  auditory,  olfactory,  gustatory,  and  space  senses. 

Visceral  and  general  bodily  sensations. 

The  cutaneous  sensations  are :  (1)  The  tactile  sense,  which  in- 


DIAGNOSIS   AND   METHODS   OF   EXAMINATION.  35 

eludes  pressure  and  contact ;  (2)  the  temperature  sense,  which  in- 
cludes the  heat  sense  and  cold  sense ;  (3)  the  pain  sense.  The  first 
two  are  special  senses,  the  last  is  a  general  sense.* 

To  test  the  tactile  sense,  blindfold  the  patient  and  use  the 
sesthesiometer.  This  is  an  instrument  with  two  rather  blunt 
points,  which  can  be  separated  or  approximated.  A  hairpin  or 
two  ordinary  pins  can  be  used  in  its  stead.  Its  use  depends  upon 
the  fact  that  the  power  to  appreciate  the  contact  of  two  points 
on  the  skin  gradually  approximated  varies  with  the  tactile  sensi- 
bility of  the  patient.  The  tongue,  finger  tips,  and  lips  are  the 
most  sensitive  points.  The  back,  arms,  and  thighs  the  least  sen- 
sitive. 

The  following  table  shows  the  average  distance  at  which  two 
points  are  appreciated  as  such  by  an  intelligent  adult : 


Tip  of  tongue,    . 

1  mm. 

(-V  i"-) 

Tip  of  toes,  cheeks, 

Tip  of  fingers,     . 

2     " 

eyelids,    . 

12  mm. 

Lips,     . 

3     " 

TemiDle, 

13     " 

Dorsal  surface  of 

Back  of  hands,  . 

30     " 

fingers,    .     .     . 

6    " 

Neck,  .... 

35     " 

Tip  of  nose,    .     . 

8    " 

Forearm,  leg,  back  of 

Forearm,    .     .     . 

9    " 

foot, 

40     •' 

Back,  .        .        .        60-80    " 

Arm  and  thigh,  . 

80    " 

The  figures  vary  somewhat  with  the  thickness  or  softness  of 
the  skin  and  with  the  dulness  or  keenness  of  the  nervous  organi- 
zation. If  the  distances  are  double  those  given  above,  it  may  be 
considered  in  most  cases  abnormal. 

The  tactile  sense  may  also  be  tested  by  the  writing  method 
(Rumpf).  Figures  or  letters  are  written  upon  the  skin  with  a 
hard-pointed  instrument,  and  the  patient  asked  to  tell  them. 
The  figures  drawn  are  made  larger  or  smaller  in  accordance  with 
the  decrease  or  increase  of  sensibility.  The  following  table  shows 
the  different  sizes  as  appreciated  on  the  normal  skin : 

Fingertips, 0.5  cm.  (|  in.)      high 


Palm, 1 

Neck 1 

Cheeks, 1 

Forehead, 1 

Arm,  forearm,  and  back  of  hand,    .      1.5  to  3.5 

Scapula 1,5  to  3.5 

Calf  and  sole 3 


'     (I  to  I  in.) 
'     (H  in.) 


*  Psychologists  deny  the  independence  of  the  pain  sense  and  assert  that  it  is  only 
a  quality  or  modification  of  other  senses. 


36 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


The  sense  of  contact  which  is  a  form  of  tactile  sense  is  tested 
by  drawing  one's  finger  or  a  bit  of  cotton  Ughtly  over  the  skin. 
The  sense  of  locahty  or  power  to  localize  a  point  on  the  skin  that 
has  been  touched  varies  with  the  tactile  sense  and  with  the 
muscular  sense.  It  is  tested  by  placing  the 
finger  lightly  on  a  given  spot  and  telling  the 
patient  with  closed  eyes  to  place  his  finger 
on  the  part  touched.  He  should  come  with- 
in 5  cm.  of  it.  In  slight  degrees  of  anaes- 
thesia dependent  upon  disease  of  the  sensori- 
motor areas  of  the  cortex  of  the  brain,  this  is 
an  important  test.  Further  tests  may  be 
made  by  moving  points  along  the  skin  and 
asking  the  patient  to  indicate  the  direction 
of  the  motion ;  or  by  laying  various  shaped 
objects  on  the  skin  and  asking  the  patient 
to  tell  their  shape  or  position.  Still  another 
method  is  recommended  by  Oppenheim.  It 
consists  in  testing  at  the  same  time  with  the 
festhesiometer  symmetrically  situated  parts 
of  the  skin  on  the  two  sides  of  the  body. 

To  test  the  pressure  sense,  use,  if  desired, 
the  bar  gesthesiometer.  A  more  convenient 
way  is  to  have  the  patient  rest  the  hands  on 
a  table  and  then  try  and  determine  the 
weight  of  different  objects.  The  lightest 
weight  that  can  be  appreciated  on  the  hands 
or  face  is  one  of  about  0.03  gram  (gr.  I). 
Differences  of  light  weights  of  1  and  5  grams 
and  of  25  and  30  grams  are  about  all  that  can 
be  ordinarily  appreciated  by  the  skin.  Much 
smaller  differences,  of  0.5  to  2  grams,  can  be 
detected  if  great  care  is  used.  Weighted 
rubber  balls  may  be  used  in  the  foregoing 
test.  I  prefer  to  use  differently  weighted 
metal  bodies,  held  by  a  wire.  Pressure  sense 
is  acute  on  the  forearm  and  abdomen,  where 
locality  sense  is  feeble;  also  on  the  brow, 
temples,  and  back  of  the  hand. 

Most  of  the  above  tests  are  not  ordinarily 
needed.  With  two  pins,  using  the  heads,  the  presence  and  de- 
gree of  anaesthesia  can  be  detected  and  approximately  measured. 
The  temperature  sense  is  tested  by  test-tubes  filled  with  hot 
and  cold  water,  or  by  using  hot  and  cold  spoons,  or  roughly  by 
breathing  and  then  blowing  on  the  part.  A  thermo-^sthesiome- 
ter  may  be  used.     This  has  a  round,  flat  surface  1  cm.  in  diame- 


FiG.  27.— Combination 

^STHESIOMETER. 


DIAGNOSIS   AND   METHODS    OF  EXAMINATION  37 

ter,  and  contains  in  its  terminals  thermometres  by  which  the  de- 
gree and  differences  in  temperature  may  be  noted  (Fig.  27).  A 
small  heated  or  chilled  surface  is  appreciated  much  less  easily 
than  a  large  one.  The  indifferent  range  where  objects  are  felt  to 
be  neither  warm  nor  cold  is  from  27"  to  30°  C.  (80. 6""  to  80"  F.). 
Fine  differences  (0,2°  to  1.5°  C.)  are  appreciated  above  the  in- 
different range.  Lower  down  in  the  scale,  differences  from  V  to 
1.8°  C.  (2°  to  8°  F.)  are  appreciable.  It  may  be  considered  a  mor- 
bid symptom  if  temperatures  of  60°  to  65"  F.  are  not  felt  as  cold, 
or  temperatures  of  86°  to  95°  F.  are  not  felt  as  warm ;  also  if  be- 
tween the  ranges  of  1°  C.  (32°  F.)  and  40°  C.  (104°  F.)  differences 
of  2°  C.  are  not  appreciated. 

A  painful  degree  of  sensitiveness  to  heat  or  cold  sometimes 
exists.  These  conditions  are  called  hyper-thermalgesia  and  hyper- 
cyalgesia  (Skinner,  Starr).  When  the  heat  or  cold  is  intense,  a 
sensation  of  pain  is  felt.  Cold-iDain  is  produced  more  easily  in 
some  places,  such  as  the  elbow,  than  others,  as,  for  example,  the 
finger  tips.  Cold-pain  is  produced  by  temperatures  of  from 
+2.8°  C.  to  —11.4°  C.  Heat-pain  is  i3roduced  by  temperatures  of 
from  36.3°  C.  to  52.6°  C. 

The  pain  sense  is  tested  by  pricking  the  skin  with  needles  or 
the  sharp  points  of  an  sesthesiometer.  The  faradic  battery  with 
metal  points  or  a  wire  brush  may  also  be  used.  Instruments  for 
pinching  the  skin  and  measuring  the  sensibility  by  the  strength 
of  the  pinch  have  been  devised.  The  power  of  localizing  pain  is 
lessened  in  proportion  to  the  analgesia. 

The  muscular'  sensihility,  i.e.,  the  general  or  pain  sensation  of 
muscles,  is  tested  by  passing  the  faradic  current  through  the  part. 

Pain  and  temperature  sense  are  usually  affected  together. 

Belayed  Sensation.— The  time  taken  for  a  sensation  to  be  felt 
and  produce  a  voluntary  response  is,  for — 

A  touch  on  the  hand,  about       .        .        .0.12  second 
"      "    foot,         "  ...  0.17      " 

Hearing, 0.13      " 

Sight, 0.16      " 

Taste, 0.15      " 

The  tactile  sense,  as  well  as  the  other  special  and  the  general 
sensations,  may  show  a  delay  in  conduction.  The  tactile  sense 
especially  should  be  tested  on  this  point.  The  delay  may  amount 
to  several  seconds. 

Double  Sensations  or  Polya;st7iesia.— When  the  touch  of  one 
point  is  felt  as  two  or  more,  the  symptom  is  known  as  polyses- 
thesia. 

Referred  sensations  and  allochiria  are  described  under  Symp- 
tomatology. 


38 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Tests  for  the  Condition  of  the  Special  Sense  of  Muscles,  Joints, 
and  Tendons,  i.e.,  for  J. toa.'«'«.— Anaesthesia  of  the  special  sen- 
sorv  nerves  of  the  muscles,  joints,  and  tendons  causes  ataxia  and 
inco-ordination.  Muscle  anaesthesia  causes  chiefly  a  loss  of  iceight 
stn.se  or  loss  of  power  to  determine  Aveights.  It  is  tested  by  the  use 
of  weights  suspended  by  a  string  so  as  to  exclude  pressure  sense; 
also  by  causing  the  patient  to  squeeze  a  dynamometer  up  to  a 
certain  fixed  number. 

In  articular  and  tendonous  anaesthesia 
there  is  loss  of  posture  sense.  It  is  tested  by 
the  physician's  moving  the  patient's  limbs 
and  having  the  blindfolded  patient  tell 
in  what  direction  the  movement  is  made. 
Or  he  is  told  to  follow  wath  one  limb  the 
movements  which  the  examiner  makes 
with  the  other. 

Muscular,  articular,  and  tendonous  an- 
aesthesia usually  exist  together;  there  is 
then  a  combined  ataxia.  Combined  ataxia 
shows  itself  in  standing  and  in  locomotion 
and  other  voluntary  movements.  Thus  we 
have  a  static  ataxia  and  locomotor  or  motor 
ataxia.  Static  ataxia  or  inability  to  stand 
(or  sit)  without  swaying  or  irregular  move- 


FlG. 


No.  1.  ^'«-  -• 

29.— Ataxiagrams.     No.  1,  Made  with  eyes 
open;  No.  2,  made  with  eyes  closed. 


ments  is  tested  by  making  the  patient  stand  with  the  eyes  closed 
and  the  heels  and  toes  close  together. 

Normally,  the  head  moves  not  over  an  inch  in  this  position, 
and  the  patient  holds  the  liead  and  body  more  rigid  with  the 
eyes  closed  than  with  them  opened.  In  ataxic  states  the  reverse 
is  true,  and  decided  swaying  or  even  complete  loss  of  equilibrium 
occurs  with  the  eyes  closed,  or  even  with  the  eyes  open,  and  the 
base  narrowed  by  putting  the  feet  together.  This  phenomenon 
is  called  the  "  Brauch-Romberg  symptom."  In  static  ataxia,  mus- 
cular and  articular  sensations  are  both  involved.  The  degree  of 
this  can  be  accurately  measured  by  the  ataxiagraph.     With  the 


DIAGNOSIS   AND   METHODS   OF   EXAMINATION.  39 

eyes  open  a  healthy  person  standing  erect  with  feet  together  tends 
to  sway  forward.  The  antero-posterior  excursion  of  the  head 
averages  3.7  em.  (H  in.),  the  maximum  being  9  cm.(3i  in.).  The 
lateral  excursion  averages  1.9  cm.  (f  in.),  maxnnum  being  5.4  cm. 
With  the  eyes  closed  the  antero-lateral  excursion  averages  3.4 
cm.  m  in.),  maximum  3^  in. ;  the  lateral  excursion  1.9  cm.  (If  in.), 
maximum  (3.8  cm.  (2|  in.). 

In  other  words,  the  person  stands  a  little  steadier  with  the  eyes 
closed,  the  average  excursion  being  1^  x  f  in.  with  eyes  open,  1^ 
X  f  in.  with  eyes  closed  (Bullard  and  Brackett). 

Ataxia  of  motion  is  tested  by  the  gait.  The  patient  can- 
not walk  a  straight  line  and  cannot  walk  without  watching  the 
floor  with  the  eyes.  The  arms  cannot  be  moved  in  a  co-ordi- 
nate way.  With  the  eyes  closed,  the  patient  cannot  place  the  fin- 
ger on  the  tip  of  the  nose,  or  lobe  of  the  ear,  or  any  indicated  spot. 
Ataxia  of  motion  involves  especially  the  articular  and  ten- 
donous  sensations,  but  not  these  exclusively. 

It  may  be  measured  by  noting  how  close  the  patient  keeps 
upon  a  given  line  ten  feet  long  in  Avalking;  how  near  he  can 
place  the  finger  upon  the  centre  of  a  board  marked  like  a  target. 
The  patient  is  placed  ten  feet  away,  and  made  to  walk  directly 
at  it  and  place  the  finger  in  the  centre. 

To  sum  up  the  foregoing,  we  have : 


Ataxia 


Due  to 


Muscular  anaesthesia 

Articular  and  tendonous  anaesthesia. 
Combined  forms,  e.g.,  static  ataxia. . . 


Locomotor  ataxia. 


Tested  by 


Weights,  etc. 
Position  of  limbs. 
Co-ordinate  move- 
ments. 
Station  and  gait. 


There  are,  besides  this,  certain  forms  of  inco-ordination  which 
are  allied  to  tremor,  and  are  disorders  of  the  sensori-motor  corti- 
cal areas  or  efferent  nerve  tracts.  Nor  is  it  absolutely  established 
that  in  the  above-described  forms  of  ataxia  there  is  not  an  in- 
volvement of  the  efferent  nerve  mechanism. 

Visio7i. — The  special  modes  of  examination  are  given  under 
the  head  of  Diseases  of  the  Optic  Nerve  and  Ocular  Muscles.  The 
special  points  which  the  neurologist  must  investigate  are  visual 
acuity,  astigmatism,  errors  of  refraction,  limitation  of  the  visual 
field,  exophthalmia,  retraction  of  the  bulb,  color-blindness,  the 
state  of  the  pupil  and  its  reflexes. 

Hearing.— The  special  methods  of  examination  are  given  else- 
where. The  points  chiefly  to  be  investigated  are  acuity,  range, 
bone  conduction,  aerial  conduction,  electrical  reactions. 

Seiise  of  S7neU.—See  p.  107. 

Sense  of  Taste.— See  p.  146. 


CHAPTER  lY. 

THE   CAUSES  AND   THE  PATHOLOGY   OF  NERVOUS 
DISEASES. 

General  Etiology. 

The  subject  of  the  causes  of  nervous  diseases  must  be  studied 
from  two  points  of  view. 

First,  w^e  must  learn  the  predisposing  and  exciting  causes  of 
nervous  diseases  in  general.  Second,  we  must  learn  the  causes  of 
the  particular  pathological  change  which  constitutes  the  disease. 

I.  The  causes  predisposing  to  nervous  disease  relate  to  age, 
sex,  condition,  heredity,  race,  climate,  civilization,  occupation, 
habits,  diatheses,  infections,  and  poisons. 

Age  and  Developmental  Influences. — In  early  age,  paralyses  and 
convulsive  troubles  are  more  frequent,  while  sensory  neuroses 
are  rare.  In  adolescence,  many  severe  constitutional  neuroses  and 
neuropathic  tendencies  develop,  but  organic  disease  is  rare.  In 
adult  life,  the  inflammatory  and  degenerative  troubles  are  at  their 
height.  In  old  age,  those  disorders  which  are  dependent  on  dis- 
ease of  the  blood-vessels,  such  as  apoplexies  and  softening,  appear. 

The  special  nervous  defects  and  disorders  more  especially  as- 
sociated with  early  developmental  influences  are  these  (Clouston) : 

1.  Of  the  eml^ryonic  stage :  Acephaly,  genetous  idiocy. 

2.  Of  the  period  of  most  rapid  brain  growth — birth  to  seven 
years:  Convulsions,  pavor  nocturnus,  tubercular  meningitis,  men- 
ingeal hemorrhage  and  encephalitis,  epilepsy,  idiocy,  infantile 
paralysis,  neurotic  fever,  febrile  delirium. 

3.  Of  the  period  of  co-ordination  of  motion  and  emotion — seven 
to  thirteen:  Chorea,  epilepsy,  asthma,  migraine,  myopathies, 
hereditary  degenerations  of  the  cord. 

4.  Puberty  and  adolescence— thirteen  to  twenty-five:  Epilepsy, 
neurasthenia,  hysteria,  migraine,  sexual  perversions,  paranoiac 
tendencies,  hereditary  myopathies  and  myelopathies,  insanities. 

AS'eo?.— Sensory  and  functional  disorders  are  more  frequent  in 
women ;  motor  and  organic  disorders  more  frequent  in  men. 

Condition  and  Occujmtion.—^o  general  facts  will  be  laid  down 
here.  Celibates,  however,  it  may  be  said,  suffer  more  from  ner- 
vous disorders  than  married  people.  It  will  be  shown  later  that 
certain  occupations  entail  special  nervous  disorders,  and  that 
in-door  life  jjromotes  functional  nervous  diseases. 


CAUSES   AND  PATHOLOGY.  41 

Habits. — Excessive  indulgence  in  alcohol  is  a  most  prolific 
cause  of  nervous  disease,  chiefly  by  the  action  of  this  substance 
on  the  blood-vessels  and  the  stomach.  Excesses  in  eating,  in  tea- 
drinking,  irregularity  in  sleeping,  and  bad  habits  of  working  pre- 
dispose to  nervous  disease.  Sexual  excesses  are  usually  the  result 
rather  than  the  cause  of  nervous  disorders. 

Heredity.— There  are  few  nervous  diseases  which  are,  strictly 
speaking,  inherited.  But  an  over-irritable,  unstable,  inadequately 
developed,  and  badly  nourished  nervous  system — one  with  a  ten- 
dency to  disease— may  be  inherited.  This  is  known  as  the  neuro- 
pathic constitution.  Excessive  intellectual  labor  and  mental 
strain  during  the  time  when  children  are  being  i^ropagated 
tends  to  produce  a  neuropathic  taint  in  the  descendants. 
When  both  parents  are  themselves  of  a  highly  nervous  tempera- 
ment, their  children  are  apt  to  be  more  so.  The  existence  of  one 
of  the  severe  forms  of  constitutional  nervous  disease,  Uke 
epilepsy  or  hysteria,  in  one  parent  is  likely  to  produce  neuro- 
pathic children.  Intermarriage  does  not  cause  neuroses,  un- 
less father  and  mother  are  of  closely  alike  temf)eraments. 
Excessive  alcoholic  indulgence  in  one  or  both  parents,  syph- 
ilis, injuries  or  fright  to  the  mother  during  pregnancy,  may  result 
in  neurotic  children.  The  mother  transmits  neuroses  and  neuro- 
tic tendencies  more  than  the  father.  A  certain  form  of  nervous 
disease  may  not  be  transmitted  in  the  direct  line,  but  will  be 
found  in  different  branches  of  the  same  family,  as,  for  example, 
in  uncle,  nephew,  and  cousin.  This  is  then  called  a  "family dis- 
ease." 

Climate  and  Cimlization. — ]S'ervous  diseases  are  most  frequent 
in  temperate  climates,  and  in  those  which  are  dry  and  elevated. 
They  increase  with  the  progress  of  civilization  and  the  greater 
strain,  complexity,  and  luxury  of  modern  social  life.  Those 
organic  nervous  diseases  which  are  largely  dependent  on  vascu- 
lar disease  are  frequent  in  the  poorer  classes  among  whom 
syphilis,  alcoholism,  and  bad  feeding  prevail.  Functional  and  de- 
generative disorders  are  frequent  in  the  higher  classes.  ]S^ervous 
diseases,  if  we  except  those  of  the  degenerative  type,  prevail  more 
in  urban  populations. 

Diatheses. — The  rheumatic  and  gouty  diatheses  predispose  to 
nervous  troubles,  more  especially  those  which  are  of  a  peripheral 
and  functional  nature,  Lith^emia,  a  condition  in  which  the  pro- 
ducts of  tissue  waste  are  not  properly  oxidized  and  eliminated, 
has  a  similar  influence. 

Trauma  and  Shock. — Hemorrhages  and  trauma  may  be  a  di- 
rect cause  or  may  predispose  to  nervous  disease.  Trauma  and 
shock  may  cause  functional  diseases  such  as  neurasthenia,  or  may 
lead  to  the  development  of  insanity  or  indirectly  to  degenerative 


42  DISEASES   OF  THE  NERVOUS   SYSTEM. 

organic  disease.  Mental  shock,  and  especially  a  fright,  oftener 
than  severe  bodily  injury,  leads  to  the  development  of  functional 
neuroses.  Hemorrhages,  exhaustion  from  excessive  work,  and 
anxiety  are  potent  causes. 

Infections.— In  comparison  with  their  frequency,  the  infective 
fevers  are  not  great  factors  in  producing  nervous  disease,  but 
practically  they  often  play  an  important  part.  Scarlet  fever  is 
the  most  dangerous  disorder  in  this  respect.  Measles  perhaps 
ranks  next,  then  follow  diphtheria,  typhoid  fever,  and  pertussis. 
Among  chronic  infections  syphilis  ranks  first;  malaria,  the  pel- 
lagra, and  beriberi  are  also  to  be  mentioned. 

Poisons. — Alcohol,  tea.  coffee,  and  lead,  mercury,  copper,  arse- 
nic, are  to  be  placed  among  the  frequent  causes  of  nervous  disease. 

Reflex  Causes. — Among  other  causes  are  local  disease  of  vis- 
cera, such  as  renal,  uterine,  and  ovarian  diseases,  dysi^eptic  and 
liver  disorders,  visual  and  auditory  troubles. 

II.  The  causes  of  particular  pathological  types  of  disease. 

Inflammatory  diseases  of  the  nervous  system,  as  of  other  sys- 
tems, are  caused  almost  always  by  microbic  infection.  This  is 
brought  about  directly  by  injury  and  exposure  to  external  agen- 
cies or  indirectly  through  the  blood.  Inflammatory^  disorders  oc- 
cur oftenest  in  early  and  middle  life,  and  in  men  oftener  than  in 
women.  Degenerative  diseases  are  observed  oftener  in  middle  and 
later  life,  and  result  from  excessive  nervous  strain,  syphilis,  ex- 
posures, poverty,  chemical  poisons,  alcohol.  Heredity  is  also  an 
important  factor. 

Diseases  of  the  blood-vessels  occur  in  middle  and  later  life. 
Bright's  disease,  the  gouty  diathesis,  alcohol,  syphilis,  over-feed- 
ing, and  chemical  poisons  such  as  lead  are  among  the  causes. 

Functional  sjjasmodic  diseases  usually  develop  early  in  life 
when  general  in  character,  like  epilepsy  and  chorea;  but  later  in 
adult  life  if  local,  like  writer's  cramp  and  wry-neck.  They  often 
follow  infective  fevers.     Hereditary  influence  is  here  important. 

Functional  sensory  disorders  rarely  begin  before  the  age  of 
seven  to  ten,  and  are  more  common  in  women  and  in  temperate 
climates.  A  certain  class  of  them,  however,  like  facial  neuralgia, 
develop  with  the  degenerative  period  of  life. 

General  nutritional  disorders,  like  neurasthenia,  are  more  fre- 
quent in  youth  and  middle  life,  in  active  and  new  civilizations, 
in  temperate  climates,  especially  those  which  are  dry  and  cool  or 
elevated. 

Diseases  of  the  peripheral  nerves  are  caused  by  injuries,  and  by 
poisons  like  alcohol  or  infections  like  that  of  beriberi  or  by  the 
auto-toxiemia  of  gout,  rheumatism,  and  diabetes.  They  occur 
chiefly  in  early  and  middle  life. 


CAUSES   AND   PATHOLOGY.  43 


General  Pathology. 

The  nervous  system  is  composed  of  nerve  cells,  nerve  fibres, 
connective  tissue,  the  neuroglia,  blood-vessels,  and  lymjphatics. 
Its  disorders  involve  one  or  more  of  the  above  tissues. 

The  following  is  a  list  of  the  forms  of  disease  which  affect  the 
nervous  system : 

1.  Malformations,  agenesis. 

2.  Hyperj^mia,  anaemia,  haemorrhage,  oedema,  and  arterial  and 
venous  diseases. 

3.  Inflammations. 

4.  Degeneration  and  atrophy,  softening,  sclerosis,  gliosis. 

5.  Tuberculosis  and  syphilis. 

6.  Tumors  and  parasites. 

7.  Nutritive  and  functional  disorders. 

I^YFLAMMATiON. — The  pathology  of  most  of  the  above  types  of 
disease  will  be  given  elsewhere,  and  does*  not  call  for  discussion 
here.  It  is,  however,  of  the  utmost  importance  that  the  student 
have  a  clear  understanding  of  the  nature  of  inflammation  and 
degeneration  as  they  affect  the  nervous  tissue.  Inflammation  is 
a  morbid  process  which  has  to  deal  primarily  with  blood-vessels, 
lymphatics,  and  connective  tissue.  Inflannuation,  teleologically, 
is  the  reaction  of  the  organism  to  an  irritant.  Wherever  there  is 
inflammation,  there  is  irritation.  The  irritant  in  inflammation  is 
practically  always  the  product  of  microbic  action  or  of  some  irritat- 
ing product  of  tissue  change.  Without  some  microbic  or  tissue 
irritant  there  can  be  no  inflammation.  We  make  this  exception 
only :  that  certain  chemical  substances,  such  as  alcohol,  arsenic, 
and  lead,  may  at  times  excite  a  form  of  inflammation  which  is, 
however,  probably,  primarily  a  degenerative  or  destructive  pro- 
cess. Inflammation,  when  the  irritant  is  removed,  tends  to  sub- 
side. It  is  a  regressive,  not  a  progressive,  process.  Bearing  these 
facts  in  mind,  it  will  be  found  that  inflammations  of  the  nervous 
tissues  never  or  very  rarely  occur  without  the  presence  of  some 
microbe  or  some  destructive  process  whose  irritant  products  excite 
inflammatory  reaction. 

Inflammations  may  be  divided  into  the  (1)  exudative  and  the 
(2)  productive  forms  (Eelafield).  The  exudative  inflammations 
maybe  simple,  without  necrosis,  with  necrosis;  purulent;  pur- 
ulent and  necrotic. 

1.  Simple  exudative  inflammation  is  accompanied  with  con- 
gestion stasis,  emigration  of  white  corpuscles,  and  perhaps  diaped- 
esis  of  red  cells,  transudation  of  blood  serum,  and  formation  of 
fibrin,  the  total  result  being  an  exudate  containing  white  blood 
cells,  now  called  pus  cells,  and  fibrin  in  varying  proportions. 


44 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


There  is,  in  some  cases,  no  destruction  of  tissue ;  and  on  subsi- 
dence of  tlie  inflammation  the  tissue  returns  to  its  normal  condi- 
tion. In  other  cases  the  inllammatory  action  destroys  some  of 
the  nerve  tissue. 

In  purulent  inflammation  there  is  great  accumulation  of  pus 
cells  and  less  relatively  of  fibrin. 

If  the  tissue  is  destroyed,  it  is  nj^in'tilent  and  necrotic  inflam- 
mation. 

In  some  exudative  inflammations  there  is  increase  of  connective 
tissue  from  the  start,  and  the  process  continues  till  the  inflam- 
mation subsides.  Most  exudative  inflammations  are  acute  or 
subacute.  Inflammatory  cedema  is  a  form  of  exudative  inflam- 
mation. 

2.  Productive  or  proliferative  inflammation  is  a  process  in 
which  there  is  little  congestion  and  exudation,  while  new  con- 
nective tissue  is  slowly  formed.  Productive  inflammation  is  usu- 
ally chronic ;  tubercular  and  syphilitic  processes  are  varieties  of 
productive  inflammation. 

The  microbes  which  are  known  to  produce  inflammations  of 
nervous  tissues  are :  the  ordinary  pyogenic  streptococcus,  the 
diiDlococcus  intra-cellularis,  the  diplococcus  pneumoniae,  a  bacillus 
like  that  of  typhoid  fever.  The  bacillus  tuberculosis  sometimes 
causes  a  purulent  inflammation.  The  supposed  rabies  bacillus, 
the  bacillus  of  leprosy,  the  anthrax  bacillus,  and  the  micro-organ- 
ism of  infectious  multiple  neuritis  may  be  added  to  the  list. 

The  principle  poisons  which  may  cause  chronic  productive  in 
flammations  are  alcohol,  lead,  and  arsenic. 

Certain  irritating  auto-toxsemic  agents,  such  as  occur  in  gout, 
rheumatism,  diabetes,  and  states  of  inanition,  appear  able  at 
times  to  cause  productive  inflammations. 

Classificatiox  of  Ixflammatio^s's. 


Form. 


Cause. 


Simple    exudative,    with  Microbic  or  toxic, 
oi-  without  necrosis. 

Purulent,   with  or  with- 
out necrosis. 


Microbic 
Microbic 


Productive  or   prolifera-   Microbic  or  toxic, 
tive. 


Example. 


Meningitis. 

Poliomyelitis. 

Meningitis  and 
encephalitis. 

Acute  purulent 
myelitis. 

Chronic  menin- 
gitis. 

Leprous  neuritis. 


Degenerations  and  Scleroses.— By  degeneration  is  meant 
a  gradual  death  of  the  nerve  cells  and  fiijres,  or  in  other  words 
of  the  parenchyma  of  the  organ.     The  cells    swell  up,  becon)8 


CAUSES  AND  PATHOLOGY.  45 

granular  and  fatty,  and  then  either  break  up  and  become  ab- 
sorbed or  enter  into  a  conditi(  )n  of  a  dead  coagulum  (coagulation- 
necrosis).  Degenerations  may  be  acute  or  chronic,  primary  or 
secondary. 

Acute  degeneration  causes  a  condition  known  as  softening  or 
necrosis.  It  is  due  to  cutting  off  of  vascular  supply,  direct  injury, 
and  to  necrotic  and  intlanmiatory  poisons.  Acute  degeneration 
may  be  folio vved  by  a  reparative  process  \ldiich  is  called  a  repar- 
ative or  reactive  inflammation,  and  which  ends  perhaps  in  -pvo- 
ducing  a  cicatrix  or  sclerosis. 

Chronic  degeneration  is  accompanied  and  follow^ed  by  a  prolif- 
erative process  which  results  in  the  production  of  connective  tis- 
sue and  sclerosis'. 

Sclerosis  is  a  i^rocess  of  connective-tissue  proliferation,  as  a 
result  of  which  the  normal  or  injured  parenchyma  is  supplanted 
by  fibrous  tissue.  The  word  sclerosis  is  usually  employed  in  de- 
scribing degenerative  diseases,  though  it  indicates  the  result 
rather  than  the  primary  nature  of  the  process. 

K  primary  degeneration  is  one  in  which  the  process  is  due  to 
inherent  defect  in  nutrition  or  to  some  poison  acting  directly  on 
the  cell  or  fibre. 

A  secondary  degeneration  is  one  that  is  due  to  a  cutting  off  of 
nerve  fibre  or  cell  from  its  trophic  centre,  or  to  an  injury  or  shut- 
ting off  of  its  vascular  supply.  Ordinarily,  in  speaking  of  second- 
ary degenerations  one  refers  to  those  due  to  the  first-mentioned 
class.  Practically,  primary  and  secondary  degenerations  often 
occur  in  the  same  disease. 

Degenerations.  Forms.  Examples. 

f  r  Myelomalacia, 

p  .  J  Progressive  muscular 

^^^^^^^ 1      atrophy, 

[  Locomotor  ataxia. 
I  (  Chronic  myelitis, 

I  Secondary  and  mixed  \  Secondary  lateral 
[  (      sclerosis. 

Degenerations  are  caused  by  certain  poisons,  such  as  arsenic, 
phosphorus,  lead,  and  the  poisons  of  infectious  disease.  Degen- 
erations also  result  from  obliterating  arteritis  such  as  occurs  in 
old  age  or  from  humoral  poisons.  Degenerations  sometimes  are 
due  apparently  to  an  inherent  defect  in  the  cell  nutrition— a  pre- 
mature death  of  it ;  also  to  causes  yet  unknown.  The  question 
as  to  whether  certain  scleroses  are  forms  of  productive  inflamma- 
tion or  of  chronic  degeneration  is  one  still  undecided.  It  is 
probable,  however,  that  many  of  the  so-called  chronic  inflam- 
mations of  the  nervous  system  are  really  degenerative  processes, 
and  that  the  primary  trouble  is  in  the  parenchyma,  and  not  in  the 
connective  tissue. 


Acute  and  Chronic 


46  DISEASES   OF  THE  NERVOUS   SYSTEM. 

Gliosis. ^It  is  contended  by  some  French  pathologists  (ChasHn, 
DC'jerine)  that  some  of  the  chronic  degenerative  diseases  are  the 
result  of  a  proliferation  of  neuroglia,  not  of  connectiv^e  tissue. 
This  process  is  called  gliosis.  Its  existence  is  not  yet  satisfactorily 
established. 

JS'utritive  and  Functional  Disorders.— A  fundamental  pecu- 
liarity of  nervous  tissue  of  man  must  here  be  noted. 

Nerve  cells  once  destroyed  never  develop  again. 

The  same  is  true,  though  not  so  absolutely,  for  the  nerve 
fibres  running  in  the  central  nervous  systerii. 

Peripheral  nerves  may  grow  again  when  cut  or  destroyed. 
They  always  grow  from  their  trophic  centre.  Nerve  tissue  in 
brain,  cord,  or  periphery  can  never  be  sutured  so  that  it  will 
functionally  unite  by  direct  union.  There  are  a  few  apparent  ex- 
ceptions. 

A  further  peculiarity  of  nervous  tissue  is  that  it  is  depend- 
ent for  its  integrity  upon  two  things,  blood  supply  and  trophic 
influences.  The  nerve  cell  is  solely  dependent  on  a  proper  sup- 
ply of  blood,  and  dies  when  this  is  withdrawn.  But  the  nerve 
fibre  is  more  dependent  on  the  trophic  influence  of  the  cell  to 
which  it  is  connected  and  of  which  it  is  a  prolongation.  It  dies 
when  cut  off  from  its  cell,  but  it  can  get  along  for  a  time  with 
but  little  direct  blood  supply. 

Underlying  nutritive  and  functional  disorders  there  exist :  A 
congenital  inadequacy  of  the  nervous  system  to  do  its  work.  Dis- 
turbances in  blood  supply.  Poisonous  conditions  of  the  body, 
due  to  substances  generated  within  or  introduced  from  without. 
Reflex  irritants.    Exhaustive  conditions  from  overwork. 


CHAPTER  Y. 
HYGIENE,    PROPHYLAXIS,    TREATMENT. 

In  the  treatment  of  nervous  disease,  the  i^hysician  attempts^ 
1.  To  reheve  distressing  symptoms.  2.  To  secure  radical  cure. 
3.  To  iDrevent  return.  This  calls  for  various  measures  which 
may  be  classed  under  the  heads  of  general  hygiene,  diet,  ex- 
ercise, climate,  hydrotherapy,  massage  in  various  forms,  electri- 
city, drugs,  external  applications,  and  surgical  intervention. 

GrENERAL  Hygiexe. — To  secure  and  keep  steady  nerves,  and 
to  prevent  the  supervention  of  organic  nervous  disease,  would 
require  a  considerable  reconstruction  of  the  present  social  system. 
1  can  only  give  some  hints  as  to  the  kind  of  advice  physicians 
should  give  to  help  along  the  desired  end.  Thus  two  people  of 
very  nervous  temperament  should  not  marry.  Children  should 
be  brought  up  to  eat  slowly  a  mixed  diet,  to  sleep  early  and 
long,  to  play  in  the  open  air,  to  learn  self-control  and  obedience. 
Their  parents  should  keep  from  them  all  infective  fevers. 
Adults  need  to  keep  in  mind  but  two  words — moderation,  exer- 
cise. With  these  they  need  not  fear  the  use  of  alcohol,  tobacco, 
tea,  coffee,  or  even  occasional  irregularities  in  sleeping  and 
eating.  Physical  and  mental  shocks,  infective  fevers,  poisons, 
and  syphilis  are  prolific  promoters  of  nervous  disease. 

Diet. — For  brain-workers  in  general,  the  best  diet  is  a  nitroge- 
nous one,  but  it  should  contain  some  fat.  Water  should  be 
drunk  plentifully  except  by  the  obese,  Avhile  the  total  amount  of 
food  should  be  less  than  when  severe  muscular  exercise  is  taken. 
The  best  foods  are  meats,  especially  fowl;  fish,  eggs,  milk, 
buttermilk,  cocoa,  green  vegetables,  and  stale  bread  with  plenty 
of  butter.  If  there  is  a  tendency  to  constipation,  farinaceous 
foods  and  green  vegetables  may  be  made  the  prominent  articles 
of  diet  in  one  of  the  daily  meals,  and  stewed  fruit  and  some 
alkaline  water  added.  The  drinks  of  brain- workers  should  be 
mainly  plain  and  alkaline  waters.  x\lcohol  can  be  taken  in 
moderation  by  some  brain- workers  without  harmful  results.  It 
may  even  secure  an  increased  capacity  for  work. 

In  persons  of  a  sensitive  and  irritable  nervous  system,  those 
who  are  classed  joopularly  as  "  nervous,"  neurasthenic,  or  hysteri- 
cal, the  above  rules  apply  as  to  a  nitrogenous  diet,  plus  as  much 


48  DISEASES   OF   THE   NERVOUS    SYSTEM. 

fat  as  can  be  digested.  There  is  a  class  of  nervous  persons  who  of 
themselves  find  that  they  cannot  take  anything  sweet  without 
producing  headaches,  rheumatic  pains,  and  dyspeptic  symptoms. 
These  persons  should  live  on  meats,  fish  with  butter,  oysters, 
cream  and  milk,  (^od-liver  oil,  and  fat  pork.  Beef  tea  with  the 
white  of  an  egg  or  some  peptonoids  forms  a  very  nutritious  dish. 
It  has  been  the  canon  of  medicine  for  many  years  that  animal  food 
must  be  the  soul  of  the  neurotic's  diet.  Most  nervous  persons 
find  in  addition  that  green  vegetables  like  spinach  agree  very  well 
with  them.  Stale  bread  can  be  taken  twice  a  day  freely,  plenty 
of  butter  being  used  upon  it.  The  dietetic  breads  from  which 
the  starch  has  been  removed  are  sometimes  useful,  but  are,  as 
a  rule,  unpalatable,  and  soon  cause  disgust. 

AVhen  a  rigid  diet  is  to  be  laid  down,  there  is  no  better  list  for 
nervous  invalids  than  the  following:  fowl;  beef;  mutton  and 
lamb;  fish,  boiled  or  broiled;  oysters;  milk;  butter;  eggs,  raw 
or  soft-boiled ;  cocoa ;  graham  bread  and  gluten  bread ;  spinach ; 
Brussels  sprouts ;  string  beans ;  stewed  fruits  slightly  alkalinized. 

Nervous  patients,  especially  hysterical  j)atients,  should  not  use 
alcohol  at  all.  Tea  and  coffee  can  be  taken  in  very  small  amount. 
The  various  alkaline  mineral  waters  may  be  used  temperately 
with  impunity,  but  none  of  them  have  much  specific  effect  in  re- 
lieving nervousness  or  curing  the  nervous  temperament. 

Water  should  be  drunk  between  or  before  meals  and  a  moder- 
ate amount  at  meals.  At  least  three  pints  of  liquid  should  be 
taken  daily.  American  neurotics  do  not  drink  water  enough. 
They  have  half-desiccated  nerves,  and  desiccation  increases  ner- 
vous irritability.  An  exclusive  milk  diet  is  indicated  in  some 
forms  of  hysteria,  hypochondriasis,  and  neurasthenia  accom- 
panied with  dyspepsia.  KarelFs  method  is  to  give  four  to  eight 
ounces  of  }varm  skim-milk  at  8  A.M.,  13  M.,  4  p.m.,  and  8  p.m.  The 
amount  is  gradually  increased. 

Exercise. — As  a  prophylactic  against  nervous  disorders,  the 
value  of  exercise,  if  taken  out  of  doors,  can  hardly  be  overesti- 
mated. Brain-workers  are  better  for  moderate  exercise,  but 
they  do  not  need  much;  and  after  twenty-five,  severe  intellectual 
work  can  rarely  be  done  by  persons  in  athletic  training.  Before 
the  age  of  twenty-five,  when  the  system  is  exuberant  with  vital- 
ity, hard  study  and  hard  physical  exercise  can  be  pursued  success- 
fully together  by  some.  Persons  of  a  neuropathic  constitution 
are  benefited  by  regular  exercise  only  when  it  interests  the  mind. 
In-door  gymnasium  exercise  with  the  ordinary  apparatus  does  no 
gootl  except  through  the  bath  that  follows  it.  In  many  forms  of 
chronic  organic  nervous  disease  exercise  is  to  be  prohibited. 
These  will  be  discussed  later. 

The  best  forms  of  exercise  are  those  (1)  which  take  one  out  of 


HYGIENE,   PROPHYLAXIS,  TREATMENT.  49 

doors,  (2)  interest  the  mind,  and  (3)  call  into  play  the  muscles  of 
the  chest  and  arm.  Walls:ing  fulfils  but  two  and  often  only  one 
of  these  conditions.  Calisthenics  are  useful  when  they  interest 
and  are  vigorously  done.  Horse-back  riding  and  bicycling  fulfil 
best  the  conditions  required  for  a  good  form  of  exercise.  And  bi- 
cycling is  the  cheaper,  more  practicable,  and  generally  better  liked 
of  the  two.  Dr.  Graeme  M.  Hammond  has  called  attention  to  the 
special  value  of  cycling  in  nervous  diseases.  Lawn-tennis,  bad- 
minton, golf,  are  all  exercises  which  can  be  taken  up  by  both 
sexes  and  at  nearly  all  ages. 

Hydrotherapy.— Hydrotherapy  is  the  science  of  applying 
water  in  the  treatment  of  disease.  The  modes  by  which  it  is 
used  in  neurological  therapeutics  are : 

I.  General  hydrotherapy : 

1.  Tonic  hydrotherapy. 

2.  Sedative  hydrotherapy. 

3.  Indifferent  baths  for  mechanical  purposes. 

II.  Local  hydrotherapy. 

1.  Tonic  Hydrotherapy. — For  purposes  of  stimulating  nutri- 
tion and  increasing  vasomotor  tone  we  employ  cold  plunges,  the 
rain  bath  or  shower,  the  jet,  cold  sponging,  cold  sitz-baths,  cold 
sheets,  local  applications  of  ice  or  cold  compresses,  or  cold  rub- 
bing, ice-bags,  brine  baths,  brief  cold  packs,  and  sea-bathing. 

The  Cold  Plunge.— Th.e  patient  fills  the  bath-tub  with  water 
at  from  60°  to  70°  F.  He  then  steps  in,  and  at  once  jumps  out  and 
rubs  himself  vigorously  until  reaction  occurs. 

The  Bain  Bath,  Jet  or  JSeedle  Bath. — The  patient  stands  in 
a  tub  Avitli  the  feet  preferably  in  warm  water,  and  alloAvs  the  cold 
water  to  fall  on  the  back  and  rest  of  the  body  for  one  or  two 
minutes.  Or  a  solid  jet  of  cool  water  is  thrown  with  force  upon 
the  back  of  the  patient,  by  an  attendant  who  stands  ten  or  twelve 
feet  away.  The  cold  jet  may  be  alternated  with  warm.  Cold 
sitz-baths  are  taken  at  a  temperature  of  70'  to  80'  F.  from  ten  to 
thirty  minutes.  The  cold  sheet  or  drip  sheet  is  used  by  wring- 
ing a  cotton  sheet  out  iik  cold  water  and  wrapping  it  suddenly 
about  the  standing  patient,  w^io  is  then  vigorously  rubbed. 

Ice-bags  are  worn  upon  the  spine  for  one  or  two  hours  once  or 
twice,  or  oftener,  daily ;  or  they  may  be  applied  for  one  or  two 
hours  at  night.  Most  of  these  measures  have  a  general  stimu- 
lating and  tonic  effect. 

The  half -hath  and  wash-off  consists  of  a  tub  partly  filled  with 
water  at  a  temperaure  of  65°  to  70°  F.  The  water  only  half  covers 
the  reclining  body.  While  lying  in  it,  the  patient  is  vigorously 
rubbed.  A  cold  cloth  may  be  laid  on  the  head.  After  five  to 
twenty  minutes,  affusions  of  colder  water  are  poured  over  the 
shoulders.  The  bath  may  be  made  as  warm  as  80  at  first. 
4 


50  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Brine  baths  contain  about  two  per  cent  of  salt,  this  being 
about  the  amount  in  sea-water— twenty-five  pounds  to  thirty 
gallons  of  water.  They  are  given  at  a  temperature  of  100^  F.  for 
twenty  to  thirty  minutes  daily,  or  cool  baths  at  a  temioerature  of 
70'  F.  may  be  given  for  five  to  ten  minutes,  the  patient  exercising 
meanwhile. 

Physiology. — Cold  applications  produce  a  local  contraction  of 
blood-vessels,  followed  by  dilatation.  There  is  usually  increased 
tissue  metamorphosis,  increased  secretion  of  urine,  increased  ab- 
sorption of  oxygen,  and  increased  excretion  of  carbonic  acid.  In 
non-febrile  persons,  cold  applications  abstract  some  heat,  but 
they  also  stimulate  the  heat-i^roducing  centres,  so  that  the  total 
effect  is  to  increase  the  heat  of  the  body.  Only  very  cold  baths 
lessen  heat  production  as  well  as  excretion  of  CO2.  Cold  baths  at 
first  accelerate  and  then  tend  to  retard  pulse  and  respiration. 
Cutaneous  sensibility  is  at  first  increased.  After  a  cold  bath 
there  is  a  sense  of  exhilaration  and  increased  muscular  power, 
provided  the  bath  be  not  too  cold  or  too  long  continued.  The 
duration  necessary  to  produce  a  reaction  varies  with  different 
people,  and  some  Aveak  and  sensitive  patients  never  can  be  made 
to  react.  Cold  baths  systematically  taken  furnish  a  kind  of 
vasomotor  gymnastics.  The  neuro-mechanism  controlling  the 
blood-vessels  becomes  more  supple,  and  the  tendency  to  local 
congestion  of  the  viscera  and  mucous  membranes  is  prevented. 
The  shower  and  jet  furnish  the  most  valuable  means  of  securing 
tonic  effects  in  nervous  disorders.  These  are  not  used  with  cold 
water  alone.  It  is  often  better  to  api^ly  at  first  a  warm  stream 
at  95'  or  10."5°  F.,  and  then  gradually  lower  it,  or  to  apply  the  hot 
and  cold  jets  alternately.  In  this  way  tonic  effects  can  be  ob- 
tained even  with  very  feeble  persons. 

2.  Sedative  Hydroihercqjy.—ThQ  sedative  baths  are  the  luke- 
warm bath,  the  wet  pack,  Turkish  and  Russian  baths,  the  hot 
sitz-bath,  pedal  baths,  compresses  and  fomentations,  and  hot- 
water  bags. 

Tfie  Lukewarm  hath  is  given  at  a  temperature  of  95  to  98  F. 
for  ten  minutes  to  half  an  hour  daily.  If  a  slight  tonic  effect  is 
desired  also,  the  patient  should  receive  an  affusion  afterward, 
i.e.,  basins  of  cool  water  at  60^  to  70'  F.  should  be  poured  over 
the  shoulders.  The  addition  of  salt  or  of  pine-needle  extract  is 
often  useful. 

The  Wet  Pack.—K  large,  thick  blanket  is  spread  upon  the  bed, 
and  upon  this  is  laid  a  linen  or  potton  sheet  wrung  out  in  cold 
water,  40'  to  GO'  F.  The  nude  patient  lies  on  this,  and  the  sheet 
is  then  smoothly  wrapped  about  him,  the  head  and  feet  not 
being  included.  The  sheet  is  carried  between  the  legs  and  made 
to  lie  evenly  in  contact  with  the  body.     Then  the  blankets  are 


HYGIENE,    PPwOPHYLAXIS,   TREfATMENT.  51 

folded  over  him,  and  other  blankets  may  be  piled  upon  this. 
Sometimes  it  is  well  to  place  hot- water  bottles  at  the  feet  and  a 
cool  compress  on  the  head.  The  patient  lies  in  this  pack  for 
thirty  to  forty-five  minutes  and  is  then  rubbed  off.  A  cool  affu- 
sion may  be  given  first.  In  delicate  patients  it  is  well  at  first  to 
simply  wrap  the  patient  in  warm  flannels  until  free  perspiration 
results.     Then  give  a  cold  affusion  or  wash -off  and  rubbing. 

In  Turkish  batJis  the  patient  is  exposed  to  a  temperature  at 
first  of  130'  or  140'  F.  for  fifteen  to  thirty  minutes,  and  then  to 
one  of  200°  F.  or  250'  F.  for  a  shorter  time.  This  is  followed  by 
massage  and  a  cold  affusion  or  plunge  or  shower.  The  effects  of 
these  baths  are  somewhat  tonic  if  not  too  prolonged.  The  pa- 
tient should  never  go  into  the  hotter  rooms  until  he  perspires, 
and  he  should  select  bath-rooms  that  are  well  ventilated,  lliis- 
sian  baths  have  similar  effects,  but  the  bodily  temperature  is 
raised  to  a  higher  degree  in  them  than  in  Turkish,  owing  to  the 
lessened  amount  of  perspiration. 

Hot  /Sit2-Baths.— The  patient  sits  in  water  at  a  temperature  of 
100'  to  125°  F.  for  twenty  or  thirty  minutes.  Sometimes  mustard 
is  added.  Hot  comjjresses  consist  of  layers  of  flannels  wrung  out  in 
hot  water  and  covered  with  dry  flannels  and  rubber  cloth.  They 
are  used  to  relieve  local  pains  and  inflammations.  They  may  be 
applied  over  the  abdomen  for  insomnia.  Hot  sprays  and  douches 
are  used  for  similar  purposes  as  fomentations.  The  hot  spinal  bag 
is  applied  at  a  temperature  not  above  120°  F. 

Phi/sioh)gij.—\^ Siviii  baths,  if  applied  in  the  form  of  the 
moist  pack,  followed  by  sponging  with  tepid  water,  lessen  tem- 
perature by  increasing  heat  radiation  and  conduction.  If  applied 
so  as  to  iDre vent  radiation,  the  bodily  heat  is  raised.  Warm  baths 
increase  the  circulation  of  the  skin,  lessen  cutaneous  sensibility, 
withdraw  blood  from  the  central  organs,  increase  the  exhala- 
tion of  CO 2,  but  lessen  the  respiratory  activity  on  the  whole. 
Nitrogenous  metabolism  is  increased  from  two  to  three  per  cent, 
and  more  urea  is  excreted.  Pulse  and  respiration  are  increased. 
Nervous  excitement  is  lessened,  and  the  general  effect  is  to  cause 
sedation  and  a  feeling  of  languor.  The  wet  pack  is  a  most  use- 
ful sedative  in  neurasthenia  and  insomnia,  and  may  take  the  place 
of  medicinal  sedatives,  like  the  bromides.  It  should  be  given 
three  or  four  times  weekly,  or  for  a  short  time  daily.  The  luke- 
warm bath  ranks  next  in  its  sedative  efficacy.  It  is  believed  that 
applications  of  water  to  the  feet  and  abdomen  especially  affect 
the  intra-cranial  circulation;  given  to  the  thighs  and  wrists,  the 
pulmonary  circulation:  cold  causing  congestion,  and  heat  anae- 
mia, of  the  distant  parts.  Cold  to  the  spine  is  believed  to  cause 
at  first  constriction,  and  later  dilatation,  of  the  thoracic,  abdomi- 
nal, and  pelvic  viscera;  heat  has  the  opposite  effect.     Hence  cold 


52  DISEASES   OF   THE   NERVOUS   SYSTEM. 

applications  are  used  to  relieve  cold  feet  and  anaemic  conditions 
ot  the  viscera. 

The  fact  must  be  borne  in  mind  that  cold  baths  and  frequent 
bathing  of  any  kind  debilitate  some  few  persons. 

Massage.— The  term  massage  may  be  made  to  include  all  the 
manipulations  of  the  body  for  the  purpose  of  curing  disease.  The 
different  methods  of  applying  it  as  classified  by  Jacoby  are: 

Effleurage  or  gentle  stroking.  The  maximum  force  to  be  ap- 
plied here  should  not  exceed  the  weight  of  the  hand.  Massage 
(X  friction  or  rubbing.  Energetic  strokes  with  one  hand  and 
strong  circular  or  to-and-fro  friction  with  the  other.  Petrissage 
or  kneading.  Tapotement  or  percussion  with  the  fingers,  hands, 
or  instruments.  Functional  movements,  passive,  active,  and  com- 
bined with  movements  made  by  the  operator. 

The  physician  maybe  reminded  that  a  male  operator  is  a  mas- 
seur, a  female  a  masseuse,  and  that  the  patient  is  massed. 

Massage  accelerates  the  lymph  and  venous  currents,  and  thus 
promotes  absorption.  It  increases  the  rapidity  and  force  of  the 
heart-beat,  except  abdominal  massage,  which  slows  the  heart  and 
helps  to  relieve  local  congestions  and  inflammatory  deposits.  It 
presses  and  stretches  the  terminal  nerve  filaments,  increases  the 
irritability  of  motor  nerves  and  the  contractility  of  muscles.  It 
may  either  increase  or  lessen  the  irritability  of  sensory  nerves 
according  as  it  is  applied.  Of  the  various  forms  of  massage,  ta- 
potement is  the  most  frequently  useful,  and  is  the  kind  almost 
exclusively  used  in  neuralgias.  It  is  applied  not  only  with  the 
fingers  and  hand,  but  also  by  the  aid  of  rubber  tubes  known  as 
muscle  beaters,  rubber  balls  with  rattan  or  whalebone  handles, 
percussion  hammers  and  various  percuteurs,  such  as  Granville's 
and  Jaeoby's, 

Massage  is  of  considerable  value  in  certain  forms  of  atonic 
neurasthenia  and  hysteria,  associated  with  anaemia,  dyspepsia, 
and  feeble  circulation,  in  hemiplegia,  in  the  paralyses  of  periph- 
eral origin,  in  functional  spasm,  especially  in  some  forms  of 
writer's  cramp  and  allied  neuroses,  in  cerebral  hypersemia,  in- 
somnia, constipation,  and  in  headache,  and  some  neuralgias, 
especially  those  about  the  head,  neck,  and  arm.  It  is  contra- 
indicated  in  heart  disease,  arteritis,  or  where  there  is  danger  of 
dislodging  a  thrombus. 

Climate  ix  Nervous  Diseases.— The  factors  which  make 
up  a  special  kind  of  climate  are : 

1.  Purity  of  air;  2,  temperature;  3,  humidity;  4,  sunhght;  5, 
rarefaction  of  the  air ;  6,  ozone ;  7,  'wind ;  8,  electricity ;  9,  soil ;  10, 
trees;  11,  social  conditions. 

Regarding  these  points,  some  facts  are  very  well  settled.  The 
air  in  the  country  is  purer  than  in  cities.     The  air  on  the  sea  and 


J 


HYGIENE,  PROPHYLAXIS,  TREATMENT.  53 

at  hi^h  levels  is  purer  than  in  other  localities.  The  temperature 
above  the  sea-level  diminishes  about  1°  F.  for  every  300  to  350 
feet,  and  is  less  the  dryer  the  air.  Alterations  in  temperature  are 
less  near  the  sea  and  less  in  the  southern  hemisphere.  The  higher 
the  elevation  and  the  colder  the  air,  the  less  moisture  does  it  con- 
tain. About  the  factors  of  ozone  and  electricity  in  the  air  little 
definite  is  known. 

Climates  are  classified  by  Weber  into  marine,  low  level  inland, 
and  high  level  inland.  These  all  have  great  variations  in  quality, 
depending  upon  their  temperature,  moisture,  etc.  As  a  general 
rule,  warm  marine  climates  and  sea  voyages  are  best  for  neuras- 
thenic invalids  of  the  irritable  type.  On  the  other  hand,  in  atonic 
and  an*mic  conditions  high  inland  climates  are  better,  at  least 
for  a  time.     Such  climates  should  not  be  too  dry  or  windy. 

In  organic  degenerative  diseases  of  the  nervous  system,  marine 
climates  and  low  Revels  are  better. 

Germany,  the  Riviera,  the  Bermudas,  the  West  Indies,  Florida, 
and  other  Southern  States  are  favorite  places  for  sending  neuras- 
thenic Americans.  Camp  life  in  the  Adirondacks  or  other  forests 
is  also  found  most  useful. 

Electricity  in  Nervous  Diseases. 

Physical. — Electricity  is  assumed  to  be  a  material  like  a  fluid, 
perhaps  a  condition  of  the  ether  itself.  It  is  not  a  force  any 
more  than  water  is  a  force,  but  it  produces  force  by  its  move- 
ments. Electrical  phenomena  are  the  result  of  the  strain  or 
stress  put  upon  the  electrical  fluid.  Physicists  assume  that  the 
electrical  fluid  exists  in  two  conditions,  positive  and  negative, 
and  we  speak  of  positive  electricity  and  negative  electricity  ac- 
cordingly. Under  ordinary  conditions  these  fluids  are  united 
and  in  equilibrium;  but  by  certain  agencies,  such  as  friction, 
heat,  chemism,  etc.,  they  can  be  separated.  We  assume  that  the 
condition  of  electrical  equilibrium  is  that  of  zero,  and  that  the 
earth's  electricity  is  at  zero.  Positive  electricity  is  raised  above, 
negative  electricity  pulled  below,  this  zero  point.  Electrical 
phenomena  result  from  attempts  of  the  fluids  to  become  equal- 
ized or  stable  again  at  the  zero  point,  just  as  the  phenomena  of 
heat  result  from  differences  of  temperature  and  those  of  gravity 
from  differences  of  pressure.  The  distance  to  which  the  electri- 
cal fluids  are  separated  from  the  zero  point  is  spoken  of  as  the 
difference  in  "  potential.*'  This  potential  corresponds  to  the  term 
"  degrees ''  in  measuring  heat.  Now,  the  greater  the  difference  in 
potential,  the  greater  the  effort  of  the  fluids  to  return  to  zero. 
High  and  low  potentials  correspond  to  high  or  low  intensity  of 
heat.     Tension  is  the  result  of  the  widely  separated  fluids  striving 


54  DISEASES  OF  THE  NERVOUS   SYSTEM. 

to  return  to  the  zero  point.  It  is  the  same  thing  as  difference  of 
potential,  and  the  term  may  as  well  be  dropped.  When  the  two 
fluids,  at  different  potentials,  attempt  to  become  equaUzed,  they 
pass  along  certain  paths  and  form  electrical  currents.  Electri- 
city will  pass  along  any  substance,  but  some  substances  conduct  it 
more  easily  than  others,  and  these  are  known  as  conchictors. 
The  relative  value  of  different  conductors  is  shown  in  the  follow- 
ing table : 

1.  The  metals;  2,  charcoal,  3,  plumbago;  4,  dilute  acids;  5,  sa- 
line solutions;  G,  pure  water;  7,  living  animals;  8,  flame.  Of  the 
metals,  silver  and  copper  are  the  best  conductors.  The  human 
body  would  have  about  the  same  conductibility  as  the  saline  so- 
lutions, if  it  were  not  for  the  skin,  which  is  a  very  poor  conductor, 
especially  when  it  is  dry.  Those  substances  along  w^hich  elec- 
tricity passes  with  great  difficulty  are  known  as  non-conductors 
or  inimlators.  The  following  is  a  list  of  some  of  these,  the  sub- 
stances arranged  in  accordance  with  their  relative  value : 

1.  Caoutchouc.  2.  Silk.  3.  Glass.  4.  Wax.  5.  Sulphur.  6. 
Resins,     7.  Shellac.     8.  Dry  air. 

The  electrical  fluids  may  be  kept  by  insulators  at  different 
potentials,  the  insulators  preventing  them  from  becoming  equal- 
ized or  reduced  to  the  same  potential.  Electricity  in  this  condi- 
tion is  called  static.     Its  study  is  called  electrostatics. 

The  electric  fluid  in  motion  is  called  dynamical  electricity, 
and  its  study  is  electrodynamics. 

Technical  Terms. — There  are  certain  technical  terms  which  it  is 
necessary  to  understand.  Electromotive  force  (symbol,  EMF)  is 
the  force  which  tends  to  set  electricity  in  motion.  An  electric 
current  results.  The  current  strength  (symbol,  C)  is  the  term 
used  to  express  the  capacity  of  the  separated  fluids  to  overcome 
resistance  in  their  attempts  to  reach  equilibrium  or  equalization 
again.  This  current-strength  or  simply  the  current,  naturally,  is 
in  proportion  to  the  strength  of  the  electromotive  force,  which  is 
constantly  disassociating  the  electrical  fluids  and  generating  the 
current.  If,  however,  as  is  always  the  case,  the  electrical  fluid 
meets  resistance  in  seeking  equilibrium,  the  resistance  dimin- 
ishes its  current.  Hence  we  have  the  formula  known  as  Ohm's 
law: 

^  Electromotive  force  EMF 

Current  strength  = ;  or  C  =    . 

Resistance  R 

All  bodies  offer  some  resistance  to  electrical  currents,  and  it  is 
important  to  have  some  standard  unit  of  resistance  for  the  sake 
of  comparison.  Such  standard  unit  has  been  adopted  and  is 
called  an  oh  m.  It  is  the  resistance  offered  to  a  current  by  a  cer- 
tain piece  of  wire  of  definite  size  and  length. 


I 


HYGIENE,   PROPHYLAXIS,   TREATMENT.  55 

A  volt  is  the  unit  of  electromotive  force,  ^.e.,  it  represents  the 
force  which  will  generate  a  certain  amount  of  electricity  in  a 
second  of  time.     A  Daniell  cell  is  of  not  quite  one  volt  strength. 

An  ampere  is  the  unit  of  working  power  or  current  strength. 
It  is  the  current  strength  produced  by  one  volt  of  electromotive 
force  working  against  one  ohm  of  resistance.  A  milliampere  is 
one-thousandth  of  an  ampere.     A  loatt  is  the  unit  of  work. 

Density. — When  a  given  current  flows  along  from  a  large  into 
a  small  conductor,  the  quantity  in  this  latter  conductor  in  a  given 
section  is  greater  and  the  current  is  said  to  be  denser.  The  in- 
strument by  which  the  strength  of  a  current  is  measured  is 
known  as  the  amperemeter:  in  medical  practice,  only  fractions  of 
the  ampere  are  used,  and  the  instrument  is  called  the  milliam- 
peremeter.  A  rheostat  is  an  instrument  for  interposing  resist- 
ance in  a  current. 

Electrical  Appliais^ces.— The  batteries  used  in  neurologi- 
cal practice  ai-e  of  three  kinds :  the  static,  the  faradic,  and  the 
galvanic. 

The  static  electrical  batteries  are  mostly  modifications  of  the 
Holtz  influence  machine.  They  are  inclosed  in  glass  to  prevent 
the  effects  of  moisture.  The  instruments  made  in  this  country 
for  medical  purposes  will  usually  furnish  electricity  all  the  year 
round.  A  cheaper  instrument,  made  on  a  different  principle  by 
Glaser,  of  Vienna,  is  recommended  by  Lewandowski.  The  bat- 
tery accessories  consist  of  an  insulated  stool  and  brass-ball  elec- 
trodes with  glass  handles.  The  patient  is  placed  on  the  stool, 
which  is  connected  by  a  rod  with  one  ot"  the  prime  conductors.  The 
battery  being  started,  the  patient  becomes  enveloped,  as  it  were, 
with  a  layer  of  electricity  which  is  at  a  very  high  potential  and 
constantly  flying  off,  being  retained  only  by  the  dry,  non-conduct- 
ing air.  The  electrode  held  by  the  operator,  and  connected  directly 
or  indirectly  to  the  other  prime  conductor,  is  now  brought  near 
the  patient.  The  electrical  fluid  bounds  to  the  zero  point  with 
such  force  that  some  of  the  metallic  parts  of  the  electrode  are 
carried  off  and  ignited,  causing  the  disruptive  spark.  The  pa- 
tient thus  is  discharged  of  the  fluid ;  but  it  continually  reaccumu- 
lates  upon  him,  and  thus  one  can  keep  on  drawing  sparks  from  all 
parts  of  the  body.  The  electric  spark  causes  a  muscular  contrac- 
tion and,  a  little  later,  a  small  punctate  red  spot.  There  is  some 
pain  connected  Avith  it,  but  as  the  electricity  penetrates  the  body 
for  only  an  infinitesimal  period  of  time,  it  directly  affects  the  viscera 
but  little,  and  is  not  dangerous.  Various  ingenious  electrodes 
have  been  devised  for  modifying  the  character  of  the  static  dis- 
charge, but  they  all  have  much  the  same  effect  as  the  spark. 

By  approximating  the  prime  conductors  so  that  they  ahnost 
touch,  and  then  connecting  the  outer  surface  of  the  two  Leyden 


56  DISEASES  OF  THE   NERVOUS  SYSTEM. 

jars  which  hang  from  the  prime  conductors  with  sponge  elec- 
trodes, one  gets  the  static  induced  current  described  by  Dr. 
William  J.  Morton.  The  special  peculiarity  of  this  current,  as 
well  as  of  the  spark  discharge,  is  that  it  is  made  up  of  electricity 
at  a  very  high  potential,  and  that,  being  composed  of  oscillating 
or  alternating  currents  of  extremely  short  duration,  the  quantity 
of  electricity  is  very  small.  The  result  is  that  when  a  muscle  de- 
generates, it  loses  its  irritability  to  the  static  current  very  early. 
The  static  current  will  thus  reveal  a  beginning-  degeneration  of 
nerve  sooner  than  the  other  currents;  it  also  promotes  tissue 
changes  more  than  other  forms.  It  sometimes  stimulates  a  greatly 
degenerated  muscle,  so  that  later  the  other  forms  will  produce  a 
contraction.  It  has  a  powerful  psychical  effect,  and  lends  itself 
readily  to  quackery. 

In  faradic  medical  hatteries  the  electricity  is  produced  by  in- 
duction. The  chief  elements  are  a  cell  and  two  coils  of  insulated 
copper  wire.  One  coil  is  placed  around  the  other,  the  outer  coil 
being  longer  and  of  finer  wire.  The  cell  generates  a  current  which 
in  turn  "  induces '"  the  electricity  which  is  received  hy  the  pa- 
tient. The  original  current  is  so  arranged  that  it  is  being  con- 
stantly broken  and  closed  or  "  made ''  again.  At  both  break  and 
make,  a  current  is  induced  m  the  inner  coil  of  coiled  wire ;  this 
forms  what  is  called  the  primary  induced  current  and  is  made 
up  of  a  succession  of  short  currents.  This  current,  though  theo- 
retically alternating,  is  really  a  current  of  one  direction.  For  the 
"make"  current  is  opposed  and  nullified  by  the  original  or  bat- 
tery current.  The  same  is  true  of  the  secondary  induced  current 
which  is  excited  in  the  outer  coil  by  the  currents  of  the  inner  coil. 
Both  currents  are  really  composed  of  a  rapid  series  of  single  cur- 
rents going  the  same  way,  and  they  each  have  a  positive  and  a 
negative  pole.  The  primary  current  is  one  of  lower  tension,  and 
is  rather  less  strong.  It  can  be  used  when  the  resistance  of  the 
parts  is  not  great  and  a  very  pow^erful  current  is  not  needed. 
The  secondary  current  is  one  of  higher  tension,  it  overcomes 
resistance  better,  and  can  be  employed  in  connection  with  the 
wire  brush  and  in  auiesthesic  conditions.  It  is  also  the  current 
used  in  measuring  the  strength  of  the  faradic  application,  as  will 
)je  shown  later.  The  current  of  the  secondary  coil  resembles  that 
of  the  static  induced  current.  It  has,  however,  a  lower  potential, 
vastly  slower  alternations,  and  more  quantity.  It  can  contract 
muscle,  which  the  static  current  cannot  affect.  The  secondary  coil 
should  be  made  of  wire  of  a  standard  size,  length,  and  layers  of 
coil.  A  standard  coil  of  wire  800  metres  long,  .225  mm.  in  diame- 
ter, wound  on  a  spool  100  nnn.  long,  is  quite  generally  adopteil  now. 

Faradic  batteries  are  made  with  the  zinc-carbon  or  Grenet  cell, 
the  Leclancln',  the  silver-chloride  cell,  or  some  modification  of 


HYGIENE,  PROPHYLAXIS,  TREATMENT. 


57 


these.  For  general  use,  the  zinc-carbon  cell  is  the  most  trust- 
worthy ;  but  the  dry  silver-chloride  cell  is  the  most  convenient.  A 
dry  cell  made  with  muriate  of  ammonia  has  of  late  come  into  use. 
Galvanic  Batteries.— There  are  two  kinds  of  these  in  practical 
use.  The  one  includes  the  cells  which  act  as  soon  as  the 
circuit  is  closed ;  the  other  includes  those  which  act  only  when 
the  elements  composing  the  battery  {e.g.,  zinc,  carbon,  platinum, 
copper,  etc.)  are  dropped  in  the  exciting  fluid.  The  former  class 
(known  as  two-fluid  cells)  are  not  touched  except  to  renew  Avater 
or  add  some  chemical.  In  the  latter  (the  single-fluid  cells),  one  of 
the  elements  is  always  taken  from  the  fluid  when  the  current  is 
not  in  use.     The  first  class  of  cells  has  a  much  weaker  chemical 


Fm.  30.— Author's  Electrode  Set  (H.  E.  Stammers,  New  York). 

action  and  evolves  less  electricity  in  a  given  time.  It  includes 
the  Daniel  cell,  the  gravity  cell,  the  Leclanche  cell,  and  the  sil- 
ver-chloride cell.  Among  the  second  class  or  single-fluid  cells, 
the  zinc-carbon  cell,  known  as  the  Grenet  or  Stohrer's  cell,  al- 
ready referred  to,  is  most  used.  The  best  portable  batteries  are 
made  of  the  zinc-carbon  cell  or  the  dry  chloride  of  silver  cells. 
Stationary  or  office  batteries  are  best  made  with  the  Leclanch6 
cell  or  some  modification  of  it;  or  the  dry  silver-chloride  cell  may 
be  used.  The  electric-light  current  can  be  utilized  to  supply  con- 
tinuous and  interrupted  currents  and  for  purposes  of  the  cautery. 
It  is  expensive. 

The  ordinary  accessories  to  the  faradic  and  galvanic  batteries 
are  electrodes,  rheostat,  and  milliamperemeter. 
The  electrodes  needed  for  ordinary  purposes  are : 
1.  An  indifferent  electrode  measuring  5  cm.  by  10  cm.      2.  A 
normal  electrode,  10  sq.  cm.     3.  A  unit  electrode,  1  sq.  cm.     4.  A 


58  DISEASES   OF  THE  NERVOUS   SYSTEM. 

soft  wire  brush.  5.  Three  handles :  one  10  em.  and  one  40  cm. 
long,  one  short  handle  with  an  interrupter.  G.  A  milliampere- 
meter.     7.  A  rheostat.     (See  Fig.  30.) 

Methods  of  Application.— StsitiG  electricity  is  applied  for  fif- 
teen or  twenty  minutes  daily  or  tri-weekly.  For  general  tonic  or 
sedative  effects,  sparks  are  drawn  from  all  parts  of  the  body  ex- 
cept the  face.  In  paralysis  or  spasm  or  pain,  sparks  are  apphed 
to  the  affected  area.  For  headaches  and  cerebral  paraesthesise, 
the  electrical  breeze  is  very  useful,  but  it  must  be  strong. 

The  faradic  and  galvanic  currents  are  used  for  about  the  same 
time  and  intervals  as  the  static.  In  some  cases,  however,  the 
galvanic  current  should  be  given  daily  or  even  two  or  three  times 
a  day.  As  a  rule,  a  course  of  electrical  treatment  should  be  con- 
tinued for  six  to  eight  weeks,  and  then  discontinued  for  a  time. 

The  special  methods  used  in  applying  these  currents  are : 

1.  General  galvanization  and  faradization  or  general  electriza- 
tion. 

2.  Local  electrization  by  galvanization  of  the  brain,  of  the 
neck,  of  the  spine,  of  the  special  senses,  limbs,  and  viscera.  Or  by 
faradization  of  the  neck,  spine,  limbs,  and  viscera. 

3.  The  combined  faradic  and  galvanic  currents.  These  are 
given  bj^  means  of  the  De  Watteville  switch.  General  and  local 
electrization  can  be  given  in  this  way. 

4.  The  polar  method.  This  is  employed  chiefly  in  using  the  gal- 
vanic current.  The  indifferent  electrode  is  placed  on  the  sternum  or 
back,  and  the  other  electrode  applied  wherever  indicated. 

5.  Cataphoric  electrization  by  means  of  Peterson's  electrode. 
G.  Electrolytic  applications  are  used  in  enlarging  strictures 

and  affecting  inflammatory  deposits  and  neoplasms. 

In  general  electrization,  whether  galvanic  or  faradic,  the  in- 
different electrode  is  placed  on  the  sternum,  feet  or  back,  and 
the  other  pole  is  carried  over  the  limbs,  trunk,  neck,  and,  if  in- 
dicated, the  head.  In  some  cases,  however,  the  two  electrodes 
are  applied  together  upon  the  different  muscles  of  the  body. 
In  local  electrization,  the  large  electrode  may  be  applied  on  an 
indifferent  spot,  and  the  other  applied  to  the  affected  limb  or 
limbs,  or  the  two  electrodes  may  be  used  together  on  the  same 
segment  of  muscles.  The  details  for  galvanizing  the  brain,  special 
senses,  and  viscera  must  be  obtained  from  special  text-books. 

When  an  electrode  is  held  steadily  upon  a  part,  it  is  called 
stabile  ;  when  it  is  moved  over  it,  it  is  called  labile.  The  positive 
pole  is  called  the  anode  (An),  the  negative  the  cathode  (Ca).  The 
size  of  an  electrode  is  indicated  in  square  centimetres. 

A  formula  for  applying  electricity  may  be  written  thus: 

Anod.  galvanization,  10  ma.  5-10  cm.  daily,  stabile. 


HYGIENE,   PPwOPHYLAXIS,   TREATMENT. 


59 


This  means  that  the  positive  pole  of  the  galvanic  current  is  to 
be  apphed  steadily  at  a  given  place  daily  for  five  minutes  with 
an  electrode  of  ten  square  centimetres. 

The  terms  "ascending  ''  and  "  descending  currents"  are  rarely 

m 


Fig.  35. 


Fig.  33. 


Fig.  34. 


Figs.  31  to  36.— Cuts  showing  Motor  Points.  The  letters  refer  to  points  elec- 
trization of  which  stimulates  certain  muscles  to  contract.  These  points  vary  much 
in  different  persons.    For  details  see  De  Watteville's  *'  Medical  Electricity. ' ' 


60  DISEASES   OF   THE   NERVOUS   SYSTEM. 

used,  the  name  of  the  pole  being  emplo^^ed  instead.  Thus,  anodal 
galvanization  of  the  brain  or  arm  means  that  the  positive  pole 
is  applied  at  these  localities.  With  the  faradic  and  static  currents, 
neither  the  pole  nor  the  direction  of  the  current  makes  much 
difference. 

Electro-Diagnosis.— ^\ien  a  motor  nerve  is  cut  off  from  its 
centre  in  the  spinal  cord,  or  when  this  centre  itself  is  diseased,  the 
nerve  and  later  the  muscle  undergo  a  degeneration.  As  a  result  of 
this,  their  reaction  to  electrical  currents  is  changed,  and  we  get 
what  is  termed  "partial  degeneration  reactions"  and  "complete 
degeneration  reactions  "  according  to  the  degree  of  disturbance. 
These  reactions  are  due  mainly,  if  not  wholly,  to  the  degeneration 
in  the  terminal  nerve  fibres  and  motor  end  plates  in  the  muscle. 
When  the  muscle  alone  is  diseased,  the  reaction  is  not  changed 
until  very  late.  The  change  in  irritability  is  due  to  the  fact  that 
as  the  nerve  fibre  wastes  it  takes  an  electric  current  of  com- 
paratively long  duration  and  considerable  strength  to  stimulate  it. 

The  first  effect  is  to  lose  its  contractility  or  reaction  to  weak  cur- 
rents, then  to  extremely  rapid,  short  currents  like  the  static,  then 
to  the  faradic,  and  last  to  the  galvanic.  Such  change  is  known  as 
the  quantitative  alteration  in  electric  irritability. 

But  besides  this,  the  nerve  and  muscle  are  affected  in  a  differ- 
ent way  by  the  different  poles  of  the  galvanic  battery.  In  nor- 
mal nerve  and  muscle,  a  contraction  is  caused  more  readily  by 
the  negative  pole  than  by  the  x^ositive.  But  muscles  with  degen- 
erated nerve  supply  sometimes  respond  as  well  or  better  to  the 
positive  pole.  This  forms  what  is  called  the  qualitative  or  serial 
change  in  the  irritability  of  the  muscle. 

Finally,  degenerated  muscles  respond  more  sluggishly  than 
normal  to  the  galvanic  and  faradic  currents.  The  contraction,  in- 
stead of  being  sharp  and  jerky,  is  sluggish  and  almost  tetanic. 
This  is  called  the  modal  change  in  irritability. 

The  qualitative  change  is  only  gotten  by  placing  the  active 
electrode  over  the  muscle,  but  the  quantitative  and  modal  changes 
may  be  gotten  by  placing  the  electrode  over  the  nerve  as  well 
as  ov^er  the  muscle.  In  describing  these  changes,  the  following 
abbreviations  are  used : 

DeR  =  degenerative  reaction. 
^     AnCC  =  anode  or  positive-pole  closure  contraction. 

CaCC  =  cathode  or  negative-pole  closure  contmction. 

ApOC  —■  anode  opening  contraction. 

CaOC  =  cathode  opening  contraction. 

Te  =  tetanus. 

D  =  circuit  is  closed  and  current  flowing. 

ADTe  =  tetanic  contraction  while  the  positive  pole  is  applied 
and  the  circuit  closed. 


HYGIENE,  PROPHYLAXIS,  TREATMENT. 


61 


The  sii^n  >  means  greater  than;  <,  less  than.  Thus  AnCC 
>  CaCC  means  anode  closure  contraction  is  greater  than  cathode 
closure  contraction. 

Degenerations  in  nerve  do  not  occur  except  in  lesions  of  the 
nerve  or  spinal  cord,  and  In  very  late  stages  of  primary  atrophy 
of  muscles.  Hence  when  one  finds  degenerative  reactions,  he  can 
exclude  disease  of  the  brain,  functional  disease,  and  primary  dis- 
ease of  the  muscle.  The  following  rules  may  be  formulated  for 
testing  for  degenerative  reactions : 

Use  the  faradic  current  first. 

The  Faradic.  Current.— Y^ae  a  secondary  induction  coil  of  .225 
mm.  diameter,  800  metres  long.  The  distance  over  which  the  coil 
moves  is  divided  into  a  hundred  parts.  The  strength  of  current 
is  indicated  by  percentage  or  millimetres.  In  many  scales  it  takes 
30  to  40  mm.  of  CD  or  coil  distance  to  cause  a  muscular  contraction. 
Record  the  minimum  necessary  for  muscular  contraction,  using 
the  same  electrodes  and  in  the  same  way  as  in  testing  with  gal- 
vanism. 

The  Galvanic  Current. — 1.  Place  the  indifferent  pole  over  the 
sternum,  and  a  10  sq.  cm.  electrode  over  the  muscle.  2.  Pass  the 
current  for  one  minute.  3.  Then  find  the  minimum  strength  needed 
for  a  cathode  closure  contraction.  4.  Then  for  an  anode  closure 
contraction.  Repeat  this  test  three  times.  5.  With  a  given  cur- 
rent, note  whether  the  cathode  closure  contraction  is  stronger  than 
AnCC,  or  otherwise.  Test  this  three  times.  0.  Note  the  character 
of  the  contraction,  if  sharp  or  sluggish.  7.  Test  nerve  in  same  way. 

The  qualitative  changes  may  be  expressed  by  a  formula  like 
AnCC  =  or  >  CaCC,  i.e..,  the  positive-pole  closure  contraction  is 
equal  to  or  greater  than  the  negative-pole  closure  contraction. 
Or,  better,  the  minimum  strength  of  current  required  to  cause  a 
contraction  in  the  muscle  is  recorded  for  the  positive  pole  and  for 
the  negative.     Thus : 

AnCC  5  ma.  or  8  cells. 
CaCC  4  ma.  or  6  cells. 

Blanks  for  such  records  are  used  in  the  Post-Graduate  Clinic, 
like  the  following : 


Record  of  Electrical  Reactions. 
Case  of __ No 


Muscle.     Nerve. 


Aut.  tibial  muscle. 


Reaction  to  (  Electrode 

Galvanic  Current.    (  ....sq.  cm. 


Kierht  Side. 
AnCC  8  ma. 
CaCC  6  ma. 


Left  Side. 
AuCC  5  ma. 
CaCC  7  ina. 


Reaction  to      2d  ind.  coil.    r,ATr 
Faradic  Current.  i^ai^.. 


liight  Side. 
0 


Left 
10  CD 


G-2 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


The  following:  table  modified  from  De  Watteville  and  dia- 
^n-am  (Fig-.  37)  show  the  diseases  in  which  degeneration  reactions 
may  be  expected. 

Table  sHOWixa  the  Lesiox,  its  Result,  the  Names  of 
THE  Diseases,  and  the  Electrical  Reactions. 


Lesion  of- 


1  to  2}4. 
Cortex  to  cord. 


3,  4.  and  5. 
Corniia. 


Result. 


Paralysis, 
traetures. 


Paralysis,  degen- 
erative atrophy 
of  nerve  and 
muscle. 

con- 


2  to  2}4.         Paralysis, 
3  to  5.  traetures. 

Lat.    cols,    and  Degenerative  at- 
ant.  corn.  rophy  of  mus- 

cle. 


5  to  6. 
Trophic      cord 
centres. 


!  Degenerative  at- 
rophy of  mus- 
cle. 

Paralysis  from 
wasting  of  mus- 
cle. 

Lat<ir,  degenera- 
tion of  nerve. 


Nerve Paralj'sis :  degen 

erative  atrophy 
of  nerve  and 
muscle. 

Muscle Wasting,  paresis. 


Nerve  and  mus-| Paresis  and  atro 
cle.  phy. 


Disease. 


Hemiplegia  from  haemor- 
rhage. 

Embolism,  tumors,  lat- 
eral sclerosis. 

Acute  and  chronic  ante- 
rior poliomyelitis. 


Amyotroijhic  lateral  scle- 
rosis. 


Progressive  muscular  at- 
roph}"  (spinal  form), 
bulbar  paralj'sis;    (?). 


Neuritis  ;   from  wounds, 
toxaemia  or  pressure. 


Simple  atrophy;  primarj- 
or  idiopathic  myositis. 

Juvenile  form  of  pro- 
gressive muscular  atro- 
p  h  y  ;  pseudo- muscu- 
lar hj'pertrophy ;  other 
types  of  primary  my- 
opathies. 

Rheumatic  atrophy  and 
paresis. 


Electrical  Reaction  as 
to  Qualitative. 


Nerve:  normal. 
Muscle:  normal. 


Nerve:  DeR. 
Muscle:  DeR. 


Nerve:  normal  i 
Muscle:  partial  C 


^DeR. 


Nerve.:  normal. 

3Iuscle:  or  partial  DeR. 

When  disease  is  ad- 
vanced, iu  early  stages, 
etc. 


Muscle:  DeR. 
Nerve:  DeR. 


Nerve  and  muscle  nor- 
mal until  late  in  the 
disease. 


No  DeR.  unless  severe. 


It  should  be  said,  finally,  that  it  is  the  sluggish  contraction 
which  is  the  most  important  element  in  showing  degeneration; 
also  that  it  is  the  muscle  which  should  be  tested  most  carefully, 
as  only  over  it  does  one  get  the  qualitative  changes. 

TherapetUics:— Electricity  is  used  as  a  counter-irritant  and  as 
a  general  mechanical  tonic  in  states  of  muscular  and  nervous 
weakness.  It  is  used  in  paralysis,  spasm,  and  pain,  and  for  its 
supposed  specific  action  in  certain  functional  and  organic  dis- 


HYGIENE,  PROPHYLAXIS,  TREATMENT. 


63 


The  faradic  and  static  currents  have  a  counter-irritating,  stim- 
ulating, and  excito-reflex  effect.  The  galvanic  current  has  a  seda- 
tive and  anti-spasmodic  effect. 

Electrolytic,  cauterizing,  and  cataphoric  effects  are  also  pro- 


duced, but  are  rarely  needed  by  the  neurologist.  A  considerable 
portion  of  the  effects  of  electricity  are  psychical,  but  they  are  not 
the  less  real  or  valuable. 


CHAPTER  YL 

GENERAL  DISEASES  OF  THE  PERIPHERAL  NERVOUS 

SYSTEM. 

The  disorders  which  afifect  the  peripheral  nerves  are  hyper- 
aiinia  and  anaemia,  degeneration,  inflammation,  functional  dis- 
orders, new  growths. 

I  shall  describe  here  those  disorders  of  which  general  facts 
can  be  stated,  no  matter  where  the  trouble  is  located.  Such  dis- 
orders are  hyperaemia  and  anaemia  of  nerves,  degenerative  pro- 
cesses, inflammation. 

Next  Avill  come  a  description  of  diseases  which  affect  the  whole 
or  a  large  part  of  the  whole  peripheral  nerves  simultaneously. 
Such  disorders  are  multiple  neuritis,  neuralgia,  and  certain  other 
neuroses. 

Hyperemia. — Etiology. — This  is  a  condition  rarely  recognized 
clinically.  The  causes  are  cold,  injury,  neighboring  inflamma- 
tion, rheumatic,  gouty  poisons  and  paralytic  vasomotor  neuroses, 
metallic  and  other  poisons. 

Symptoms. — The  symptoms  are  those  of  burning,  numbness, 
and  other  parsesthesiae ;  tenderness,  pain,  and  muscular  weakness. 
Doubtless  many  forms  of  neuralgia  are  associated  with  hyper- 
ccmia. 

Pathological  Anatomy. — The  nerve  in  hyperemia  is  reddened, 
injected,  and  may  be  the  seat  of  minute  hemorrhages. 

Treatment.— A^  hypersemia  and  anaemia  are  always  secondary 
conditions,  the  treatment  is  mainly  based  on  the  cause.  The  ice- 
bag,  leeches,  counter-irritation,  cupping,  and  massage  may  be  re- 
sorted to  in  hyperaemia ;  local  stimulants,  hydrotherapy,  massage, 
nitroglycerin,  iron,  and  iodide  of  potassium  may  be  given. 

Ax.^MiA  OF  Nerves.— iS'^/oZo^y.— This  occurs  in  conditions 
of  general  anaemia  and  cachexia,  in  spasmodic  vasomotor  neu- 
roses, in  obstruction  of  blood-vessels  from  any  cause,  and  in  ob- 
literating arteritis. 

Symptoms. — Often  no  especial  symptoms  result.  Here  again, 
however,  we  may  trace  the  cause  of  pains  and  neuralgias,  espe- 
cially those  of  the  later  periods  of  life  when  arteritis  is  present. 


DISEASES    O:^   THE   PERIPHERAL   NERVES. 


G5 


Dkgenkratiox  of  Nerves. 


This  is  a  process  in  which  the  nerve  fibres  gradually  die;  the 
myelin  sheath  and  axis  cylinder  disappear,  leaving  only  a  strand 
of  connective  tissue. 

Etiology.— It  is  caused  by  destruction  of  the  trophic  centres 
of  the  nerve  or  by  cutting  the  nerve  off  from  it ;  or  by  direct 
action  of  toxic  and  inflammatory  and  destructive  agents  on  the 
nerve  fibre.  Diseases  of  the  spinal  cord,  injuries  of  nerves,  and 
toxic  agents  are  the  special  causes.  There  is  occasionally  also  a 
primary  atrophy  of  peripheral  parts  of  nerves  in  wasted  and  dis- 
used muscles. 

The  symptoms  of  nerve  degeneration  are  those  of  sudden  or 
gradual  enfeeblement  and 
loss  of  the  nerve's  func- 
tion. There  may  be  some 
evidence  of  irritation,  such 
as  pain  and  spasm.  Pa- 
ra 1  y  s  i  s ,  ansesthesia,  and 
various  trophic  and  vaso- 
motor disturbances  occur 
in  the  part  affected. 

Degeneration  of  nerves 
is  usually  secondary  to  or 
associated  with  other  dis- 
eases, and  its  special  symp- 
toms will  be  described  else- 
where. 

Pathology. — There  are 
three  forms  of  nerve  degeneration:    1.  Primary;   2.  Secondary; 
3,  Neuritic  or  toxic. 

1.  The  primary  form  is  rare,  slight  in  extent,  and  of  little  clin- 
ical significance.  In  it  there  is  simply  a  gradual  wasting  and  dis- 
appearance of  the  axis  cylinder  and  myelin  sheath.  It  occurs  in 
wasting  diseases  and  as  part  of  locomotor  ataxia  (Fig.  38). 

2.  Secondary  degeneration  or  Wallerian  degeneration.  This 
form  occurs  when  the  nerve  is  cut  across,  or  compressed,  or  de- 
stroyed by  inflammation,  neoplasms,  or  injuries.  The  peripheral 
end  of  the  cut  nerve  shows  a  loss  of  nearly  but  not  quite  all  the 
fibres  as  far  as  its  termination.  In  the  central  end,  the  degenera- 
tion only  ascends  to  the  first  or  second  node  of  Ranvier.  A  few 
fibres,  however,  degenerate  as  far  as  the  spinal  cord.  These  are 
afferent  in  function,  they  have  their  trophic  centre  in  the  periph- 
ery, and  correspond  to  the  undegenerated  fibres  in  the  periph- 
eral part  of  the  cut  nerve. 


Fig,  38.— Simple  Atrophy  of  Nerve 
IN  Marasmus. 


CO 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


"When  the  section  is  made  between  the  spinal  gangha  and  the 
cord,  the  fibres  all  degenerate  toward  the  cord,  and  even  enter  it, 
but  the  peripheral  fibres  do  not  degenerate.  Hence  the  spinal 
ganglia  are  the  trophic  centres  of  most  of   the  sensory  nerves. 


MK. 


S.G. 


Fig.  39.— Cct  showing  the  Effects  op  Section  op  Mixed  Nerves  and  Sen- 
sory Root.  P.M.N.,  3Iixed  nerve;  S.G.,  spinal  ganglion;  M.R..  motor  root;  S.R., 
sensory  root;  P.  c,  peripheral  trophic  cell.  The  dotted  line  shows  the  degenerated 
nerves. 

A  few,  however,  have  their  trophic  centre  in  peripheral  nerve 
cells. 

Degeneration  occurs  in  the  motor  nerves,  also,  when  the  cells 
of  the  anterior  horns  are  destroyed.  Hence  these  cells  are  the 
trophic  centres  for  all  motor  nerves. 

The  essential  part  of  the  nerve  fibre,  the  axis  cylinder,  is  sim- 
ply a  prolongation  of  the  process  of  a  nerve  cell.     Its  next  essen- 


FiG.  40.— Showing  Different  Stages  in  the  Process  op  Nerve  Degeneration 
ON  Second,  Third,  Sixth,  and  Ninetieth  Days  after  Section  (Ranvier). 


tial  part  is  the  myelin  sheath.  This  is  of  epiblastic  origin  and 
consists  of  a  hollow  cylinder  inclosed  in  a  thin  membrane  and 
containing  a  fatty  substance. 

In  degenerative  processes  of  peripheral  nerves  the  medullary 
sheath  is  first  affected,  then  the  axis  cylinder,  least  and  last  the 
neurilemma.     The  myelin   becomes  turbid,  splits  up  into  frag- 


DISEASES   OF   THE   PERIPHERAL  NERVES. 


67 


ments  and  droplets.  The  axis  cylinder  also  breaks  up  into  frag- 
ments or  swells  up  and  becomes  liquefied.  Extravasated  leuco- 
cytes pick  up  the  products  of  disintegration  and  form  fat-granule 
cells.  The  neurilemma  and  its  nuclei  usually  remain  intact.  The 
nerve  during  this  time  shrinks  in  volume  and  looks  grayish  and 
translucent,  or  grayish-red.  The  nerve  finally  becomes  only  a 
fibrous  cord.  Changes  can  be  seen  in  the  nerve  within  forty-eight 
hours,  and  by  this  time  its  irritability,  which  was  first  slightly 
increased,  is  lost.  In  about  two  weeks  the  disintegration  of  the 
myelin  sheath  and  axis  is  practically 
complete. 

The  process  of  degeneration  takes 
place  at  about  the  same  time  through- 
out the  wdiole  length  of  the   nerve. 
The  motor  end  plates  in  the  muscles 
are  afTected  a  little  the  earliest.      The 
fibres  of  the  central  stump  are  affected 
as  far  as  the  first  or  second  nodes  of 
Ranvier.      Later,   the  central    stump 
may   degenerate  somewhat  from  dis- 
use.    About    the   cut  end,    however, 
little  bulbous    tumors   may   develop, 
which  contain  numerous  nerve  fibrils 
and  connective  tissue. 
The    general    law    is 
that*  nerves   degener- 
ate   in    the    direction 
in    Avhich  they  carry 
impulses,  but    this  is 
not  always  the  case,  as 
is  seen  with  peripheral 
sensory  nerves. 

The  relations  of 
nerve    fibres    to  their 
centres  and  the  effects  of  section  is  shown  in  the  accompany- 
ing cuts. 

Nummary:  PeHj^heral  nerve  fibres  degenerate  when  cut  off 
from  their  trophic  cells. 

The  degeneration  begins  at  once  throughout  the  length  of  the 
nerve.  Loss  of  function  occurs  in  forty-eight  hours.  The  degen- 
eration is  practically  complete  within  two  or  three  weeks. 

The  myelin  sheath  and  its  nuclei  are  affected  first,  the  axis 
cylinder  next. 

-^he  degeneration  takes  place  in  the  direction  in  which  the 
nerve  impulse  runs  except  in  peripheral  afferent  nerves. 

The  final  stage  is  one  of  nerve  atrophy. 


m\ 


\ 


^^D 


Fig.  41.— Showing  the  Relations  of  the  Nerves 
TO  THEIR  Trophic  Centres.  S..  Sensory  nerve;  M., 
motor  nerve;  S.G.,  spinal  ganglion;  P.H.,  posterior 
horn;  A.H.,  anterior  horn;  C,  cerebralcortex.  The 
dotted  line  shows  the  degenerated  nerve. 


6S  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Within  tJie  central  nervous  system  the  degeneration  always  oc- 
curs in  the  direction  of  the  nerve  impulse.  The  axis  cylinder  is 
first  affected.  There  is  sometimes  a  preliminary  swellino;  or  hy- 
pertrophy of  the  axis  cylinder.  Dejj^eneration  with  calcification 
of  the  nerve  fibres  sometimes  occurs.  In  associative  or  commis- 
sural fibres  the  degeneration  only  extends  part  of  the  length  of 
the  nerve. 

3.  Neuritic  or  toxic  nerve  degeneration.  This  form  occurs  in 
connection  with  neuritis,  and  will  be  described  under  that  head. 

Its  chief  characteristics  are  that  the  degeneration  attacks  the 
nerve  in  segments,  that  the  axis  cylinders  are  not  so  much  affected, 
and  the  myelin  breaks  up  into  small  fatty  droplets  instead  of 
into  large  masses. 

Degenerative  processes  in  the  non-nieduUated  nervous  fibres 
have  been  observed  in  the  fine  fibres  of  the  cornea  and  in  the 
submucous  and  myenteric  plexuses  of  the  alimentary  tract. 

Regeneration  of  nerves  is  a  j^rocess  that  usually  follows  degen- 
eration. It  occurs  only  in  i3eripheral  nerves — very  little,  if  at  all, 
in  the  nerves  of  the  central  nervous  system  of  mammals.  It  is 
a  unique  process,  in  that  the  nerve  is  the  only  specialized  tissue 
that  can  grow  again  after  being  destroyed.  Regeneration  occurs 
whenever  the  trophic  centres  are  healthy,  when  the  mechanical 
ol)stacles  to  a  union  of  tli^  divided  fibre  are  not  too  great,  and 
Avhen  the  peripheral  nerve  is  not  too  completely  atrophied.  It 
occurs  most  quickly,  therefore,  when  the  cut  ends  are  carefully 
ai^posed  and  when  the  separation  has  not  lasted  for  a  long  rtme, 
i.e.,  for  years.  It  progresses  always  from  the  central  end  toward 
the  periphery.  The  fibres  of  the  central  stump  grow  out  into 
the  degenerated  j^eripheral  fibre.  Union  by  Jii^st  intention  or 
second  intention  never  occurs.  Human  nerves  cannot  be  made 
to  unite  physiologically,  but  only  anatomically. 

Regeneration  may  be  complete  in  a  few  months  in  short  nerves. 
In  the  sciatic  it  may  take  one  or  two  years.  When  regeneration 
takes  i^lace,  the  axis  cylinders  of  the  central  stump  swell  and  divide 
into  a  number  of  new  cylinders  which  pierce  or  creep  around 
the  intervening  tissue,  enter  in  bundles  the  peripheral  nerve, 
and  become  inclosed  in  new  myelin  sheaths  and  neurilemma. 

INFLAMMATION   OF    NERVES— NEURITIS. 

Anatomically  and  clinically,  there  are  two  forms  of  neuritis: 

1.  Neuritis  of  single  nerves  or  groups  of  nerves. 

2.  Multiple  neuritis. 

Pathologically,  there  are  two  forms  of  neuritis: 

1.  Interstitial  neuritis  and  perineuritis. 

2.  Diffuse  neuritis  with  parenchymatous  degeneration. 


DISEASES    OF   THE    PERIPHERAL    NERVES. 


69 


Etiologicalli/^  there  are  two  forms : 

1.  Toxic  neuritis,  from  alcohol,  arsenic,  lead,  etc. 

2.  Infective  neuritis  from  iDvogenic  organisms,  infective  fevers, 
syphilis,  tuberculosis,  leprosy,  etc. 

I  shall  follow  the  anatomical  and  clinical  classification  and 
describe,  first,  neuritis  of  single  nerves  or  groups  of  nerves;  next, 
multiple  neuritis. 

Neuritis  of  Single  Nerves  or  Nerve  Groups.— ii^^/oZ- 
ogy. — The  most  frequent  cause   of  neuritis  by  far  is  injurj',  such 


Fig.  42.— Acute  Infectious  Neuritis,  showing  haemorrhage,  connective-tissue 
proliferation,  diseased  nerve  fibres,  and  obliterated  vessel  (Rosenheim). 


as  compression,  tearing,  stretching,  cutting,  etc.  Next  comes, 
perhaps,  lead-poisoning;  after  this,  various  infections,  such  as 
typhoid  fever,  variola,  diphtheria.  Tuberculosis,  leprosy,  syphilis, 
are  also  causes. 

Si/mjJtojns.— These  are  such  as  result  from  irritation  and  paral- 
ysis of  the  nerves  affected,  and  will  be  described  under  the  head 
of  Special  Forms. 

Pathology.— Injury  may  not  cause  a  true  neuritis,  but  only  a 
secondary  degeneration.     When  inflammation  does  occur  it  is  of 


70  DISEASES   OF   THE   NERVOUS   SYSTEM. 

an  interstitial  or  perineuritic  type,  and  it  may  be  acute  or  chronic. 
In  the  former  case  there  is  hyijersemia,  with  sometimes  extravasa- 
tion of  blood.  An  exudation  occurs  into  the  fibi-ous  framework 
of  the  nerve,  with  migration  of  leucocytes.  The  inflannnation 
may  become  suppurative  or  gangrenous.  If  severe,  it  destroys 
the  nerve  fibres;  but  oftenest  the  axis  cylinders  are  not  destroyed, 
and  recovery  takes  i^lace.  Chronic  interstitial  neuritis  and  peri- 
neuritis are  accompanied  with  hyperplasia  of  the  connective  tissue, 
compression  and  more  or  less  destruction  of  the  nerve.  It  may  as- 
cend or  descend,  and  it  is  called,  accordingly,  ascending,  descend- 
ing, or  migrating  neuritis.  It  may  affect  only  certain  segments 
of  the  nerve,  when  it  is  called  segmental  neuritis  or  disseminat-ed 
neuritis.  Tubercular  and  syphilitic  neuritis  are  of  the  chronic 
interstitial  or  diffuse  type.  These  latter  forms  rarely  involve 
peripheral  nerves,  but  rather  the  intra-cranial  parts  of  the  cranial 
nerves  and  the  spinal  nerve  roots  in  meningeal  tuberculosis  or 
syphilis.  A  syphilitic  peripheral  multiple  neuritis  is,  however, 
thought  to  occur  sometimes.  Leprous  neuritis  is  a  very  typical 
form  of  proliferating  chronic  iDerineuritis.  Cancerous  neuritis 
sometimes  occurs,  and  it  is  of  the  diffuse  type,  though  sometimes 
an  actual  cancerous  process  invades  the  nerve. 

The  course,  duration,  prognosis,  diagnosis,  and  treatment  of 
the  above  types  of  neuritis  will  be  given  under  the  s^Decial  heads. 

Multiple    Neuritis    (Polyxeuritis,   Pseudo-Tabes,   Alco- 
holic Paralysis  Beri-beri,  Igxipedites,  AcRODY:jfiA). 

This  is  an  inflammatory  and  degenerative  affection  attacking 
a  number  of  nerves  simultaneously  and  characterized  chiefly  by 
wasting  and  painful  paralysis  or  by  ataxia,  with  some  motor 
weakness.     It  generall}^  runs  a  subacute  course. 

Forms. — Multiple  neuritis  may  be  of  the  paralytic  or  motor  and 
of  the  ataxic  or  sensory  type.  There  are  also  endemic  types  and 
acute  pernicious  forms. 

Etiology. — The  disease  is  due  to  infections,  to  auto-toxic  agents^ 
and  to  chemical  poisons. 

The  special  infections  are  those  causing  the  disease  beri-beri, 
the  infection  of  diphtheria,  and  probably  almost  all  of  the  exan- 
thematous  fevers,  as  well  as  of  puerperal  and  other  septic  fevers, 
cholera,  ankylostoma,  cerebro-spinal  meningitis,  and  possibly 
phthisis  and  syphilis.  The  most  common  infection  in  this  coun- 
try is  diphtheria.  In  the  West  Indies  malaria,  in  France  an  infec- 
tion causing  acrodynia,  in  Japan,  China,  and  various  other  trop- 
ical regions  the  infection  of  beri-beri  are  causes.  Probably  an 
independent  specific  infection  of  unknown  character  sometimes 
is  a  cause. 


DISEASES   OF   THE   PERIPHERAL   NERVES.  71 

The  autochthonous  or  auto- toxic  poisons  are  those  of  rheuma- 
tism and  diabetes.  An  incomplete  form  of  polyneuritis  is  some- 
times seen  as  the  result  of  exposure  to  cold  and  wet,  as  in  han- 
dling ice.     Conditions  of  inanition  sometimes  seem  to  lead  to  it. 

The  toxic  causes  from  without  are  those  of  alcohol,  arsenic, 
lead,  anilin,  ergot,  bisulphide  of  carbon,  illuminating  gas,  mer- 
cury, and  phosphorus.  Practically,  alcohol  causes  nmltiple 
neuritis  in  the  great  majority  of  cases  (30  out  of  P>1).  In  this 
country  rheumatism  and  the  infective  fevers,  especially  diphthe- 
ria, are  not  infrequent  causes,  and  the  metallic  poisons,  with 
arsenic  leading,  come  last. 

^ex. — Multiple  neuritis  occurs  oftener  in  the  female  than  in 
the  male.  This  is  due  to  the  fact  that  alcoholic  neuritis,  which  is 
the  common  form,  afTects  women  oftener.  Beri-beri  occurs  much 
oftener  in  the  male. 

Age. — Multiple  neuritis  is  essentially  a  disease  of  early  adult 
life.  Almost  all  cases  occur  between  adolescence  and  the  period 
of  degenerative  changes,  twenty  to  forty-five.  Young  children 
are  very  rarely  subject  to  it.  The  youngest  age  reported  is 
fourteen  years  (Suckling).  A  few  cases  have  occurred  in  persons 
over  sixty;  but  they  are  but  little  less  susceptible  than  children. 
In  beri-beri,  three-quarters  of  the  cases  are  between  the  ages  of 
fifteen  and  twenty-five,  6%  in  children,  1.2/^  in  old  people  (Harada). 

/Season  and  Climate. — The  sporadic  forms  of  polyneuritis  from 
alcohol  and  various  poisons  and  infections  occur  without  much 
reference  to  a  seasonal  influence.  Probably  more  cases  occur  in 
spring  and  fall,  owing  to  sudden  changes  in  temi^erature.  Beri- 
beri occurs  oftener  in  warm  weatlier.  Epidemic  influences  like 
that  causing  cerebro-spinal  meningitis  may  increase  the  number 
of  cases  of  multiple  neuritis.  Practically,  in  this  country,  the 
question  of  drink  settles  the  question  of  the  distribution  of  poly- 
neuritis. It  is  rare  in  the  temperate  rural  districts  and  smaller 
towns,  and  much  rarer  in  native  Americans  than  foreigners. 

Sexual  excesses,  exposure  to  cold  and  wet,  insufficient  diet,  are 
among  the  helping  causes. 

Symptoms  and  Course. — Polyneuritis  usually  begins  somewhat 
acutely,  but  runs  a  slow  course  of  several  months.  Very  rarely 
it  runs  a  sudden  course,  ending  fatally.  AVe  have,  therefore,  the 
ordinarily  suhacute  multiple  neuritis  and  acute  2)e?micious  mul- 
tiple neuritis.     The  endemic  infectious  forms  show  other  types. 

The  following  is  the  classification  followed : 

1.  Subacute,  multiple  neuritis. 
Motor  type. 
Sensory  type. 

Endemic  forms:  Beriberi,  etc. 
Malarial  forms. 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


2.  Acute  malignant  multiple  neuritis. 

1.  This  is  the  type  of  neuritis  produced  by  alcohol,  infections, 
poisons,  and  rheumatic  influences.  It  is  usually  chiefly  a  motor 
trouble,  but  sometimes  takes  the  sensory  or  pseudo-tabetic  form. 
Prokromata.—The  disease  often  begins  with  prodromata  last- 
in"-  several  weeks.  The  patient  suffers  from  numbness,  slight 
pains,  and  weakness  affecting  especially  the  lower  extremities. 

In  other  cases  the  attack 
comes  on  suddenly,  and  in  a 
short  time  the  most  marked 
symjDtoms^  appear. 

Onset. — There  may  be  a 
fever  for  three  or  four  days, 
with  a  temperature  of  103^  or 
104\  This  is  not  the  rule. 
Numbness  and  pains  attack 
the  feet  and  legs,  rarely  ex- 
tending much  above  the 
knees.  The  muscles  and 
nerves  are  very  tender.  The 
fingers,  hands,  and  arms  are 
often  similarly  but  less  af- 
fected. At  the  same  time 
the  skin  becomes  reddened 
or  slightly  cedematous.  The 
muscles  of  the  legs  grow 
weak,  and  in  a  day  or  two 
the  patient  may  be  unable 
to  stand.  In  a  Aveek  or  two 
there  may  be  a  comiDlete  loss 
of  power  in  the  anterior  tib- 
ial muscles  and  a  lesser  de- 
gree of  paralysis  in  the  exten- 
sors of  the  hand.  Nearly  all 
of  the  leg  and  forearm  mus- 
cles become  eventually  in- 
volved. Atrophy  sets  in  at 
the  same  time  and  very 
severe  pains  are  present. 
The  motor  cranial  nerves  are  in  rare  cases  affected,  and  pa- 
ralysis of  the  facial  or  of  the  third,  fourth,  or  sixth  nerve  has 
been  seen.  When  the  disease  is  fully  developed,  which  is  within 
a  fortnight,  there  is  paraplegia  with  foot  drop,  some  degree  of 
wrist  drop,  muscular  atrophy,  and  slight  oedema,  especially  of 
the  feet.  The  skin-reflexes  are  often,  the  knee  jerk  and  elbow 
jerk  always  lost.     There  is  some  tactile  anaesthesia,  often  with 


4:1— Alcoholic  Paralysis,  with  Foot 
Drop  and  Wrist  Drop. 


DISEASES   OF   THE   PERIPHERAL  NERVES.  73 

hyperalgesia.  Temperature  and  jDain  sense  are  also  lessened 
and  slowed  in  transmission.  The  anaesthesia  occurs  in  patches 
or  diffusely.  Muscle  and  articular  sense  are  lost  in  the  sensory  or 
pseudo-tabetic  form,  and  are  usually  somewhat  involved  in  the 
ordinary  paralytic  form.     Pain  and  sensitiveness  continue. 

The  nerves  lose  their  irritability  and  the  muscles  show  degen- 
eration reaction,  partial  or  complete,  the  characteristic  being  a 
great  variability  of  reaction  over  different  groups  of  nerves  and 
at  different  stages  of  the  disease,  and  an  early  loss  of  faradic  and 
lessening  of  galvanic  irritability.  There  is  sometimes  retinal  hy- 
peraemia  and  even  optic  neuritis.  Of  the  visceral  nerves,  the 
vagus  seems  oftenest  to  show  signs  of  involvement,  in  rapid  pulse 
and  disturbances  of  respiration.  The  sphincters  are  rarely  in- 
volved. In  such  cases  there  is,  perhaps,  involvement  of  the 
cord  or  of  the  abdominal  and  pelvic  splanchnics.  In  alcoholic 
and  occasionally  in  other  forms  of  neuritis,  mental  symptoms,  such 
as  a  low,  muttering  delirium,  are  very  often  present,  and  occasion- 
ally a  well-marked  conf usional  insanity  develops. 

The  disease  usually  reaches  its  height  in  a  week  or  two  and 
then  starts  on  a  chronic  course ;  but  it  sometimes  happens  that 
exacerbations  occur,  or  that  a  paralysis  and  atrophy  progress  for 
several  weeks  before  regression  begins.  In  alcoholic  cases  there 
is  often  great  general  prostration;  the  patients  lie  for  several 
weeks  in  a  delirious  condition,  and  finally  develop  pneumonia 
and  die. 

Some  further  details  should  be  added. 

Motor  ^ymjytoms. — The  characteristic  paralysis  of  multiple 
neuritis  is  a  quadruplegia,  all  four  extremities  being  involved. 
The  sj^ecial  characteristic  is  the  foot  drop,  which  is  indicative  of 
alcoholic  neuritis,  just  as  wrist  drop  is  of  lead  palsy.  The  paral- 
ysis is  typically  a  peri]3heral  one.  It  affects  the  feet  and  legs, 
hands  and  forearms.  It  usually  involves  the  anterior  tibial  muscles 
more  than  the  calf  muscles,  but  sometimes  the  reverse  occurs. 
The  muscles  become  wasted  and  flabby.  They  soon  lose  in 
bad  cases  all  reaction  to  faradism,  and  they  require  a  strong  gal- 
vanic current  to  produce  a  contraction.  In  anterior  poliomyelitis, 
on  the  other  hand,  the  diminution  in  galvanic  irritability  comes 
on  only  after  weeks  or  months.  Hence  an  early  loss  of  galvanic 
as  w^ell  as  faradic  reaction  is  an  important  sign  of  neuritis.  As  the 
nerve  and  muscle  recuperate,  the  galvanic  irritability  increases. 
After  a  time,  if  the  paralysis  is  great,  contractures  occur.  The 
feet  are  extended,  the  legs  are  flexed  on  the  thighs,  and  are  al- 
most immovable,  and  the  patient's  condition  is  most  pitiable. 

Sensory  SymjJtoms.—'Numhness,  hyperesthesia,  severe  pains 
(dull  and  sharp),  burning  sensations,  great  tenderness,  all  occur, 
and  are  very  marked  symptoms.     They  are  felt  mostly  in  the  feet, 


7-i  DISEASES   OF   THE   NERVOUS   SYSTEM. 

legs,  and  hands.  Hypera^sthesia  is  usually  followed  by  anaesthesia 
to  touch  and  somewhat  to  pain  and  temperature.  The  transmis- 
sion of  these  latter  two  sensations  is  delayed.  The  anaesthesia 
sometimes  occurs  in  patches,  at  other  times  diffusely  over  foot, 
le^^  and  hand.  Muscular  and  articular  anaesthesia  are  common, 
and  in  the  sensory  form  are  the  dominant  symptom,  causing  an 
ataxia  of  gait  and  station.  The  other  special  senses  are  not 
affected  except  in  rare  cases,  in  which  there  is  optic  neuritis. 

Vasomotor  and  Trophic  Symptoms.— There  is  often  osdema, 
sometimes  redness  of  the  skin ;  occasionally  the  epidermis  of  the 
soles  and  palms  peels  off.  Glossy  skin  and  profuse  perspiration 
are  rare.     Eruptions  and  ulcers  do  not  occur. 

Mental  Symptoms.— The  most  common  mental  disturbance  is 
that  so  often  seen  in  acute  alcoholism,  viz.,  a  muttering  delirium. 
This  is  associated  with  great  general  vital  depression. 

If  a  true  insanity  develops,  it  also  resembles,  as  a  rule,  alco- 
holic insanity  or  acute  confusional  insanity.  The  characteristic 
symptoms  are  a  curious  degree  of  forgetfulness,  together  with 
many  and  varying  delusions  rapidly  succeeding  each  other. 
These  often  relate  to  the  pains  and  parsesthesia  from  which  they 
suffer.  They  think  that  there  are  gloves  on  their  hands  or  that 
something  is  on  their  feet.  They  often  think  that  they  have 
been  out  walking  or  riding..  They  are  talkative,  incoherent,  and 
sleepless. 

Organic  Centres.— The  bladder  is  ocasionally  affected  for  a 
short  time,  the  other  centres  not  at  all.  This  freedom  from  in- 
volvement of  the  sphincters  is  an  important  characteristic  of  the 
disease  in  distinguishing  it  from  myelitis.  From  the  foregoing 
it  will  be  seen  that  the  dominant  symptoms  are  paraesthesia, 
pains  (burning,  lancinating,  and  dull),  muscular  tenderness,  some 
anaesthesia,  paralysis  affecting  especially  the  lower  extremities 
and  causing  foot  drop,  muscular  wasting,  with  degeneration 
reactions;  with  no  involvement  of  the  sphincters;  sometimes 
peculiar  mental  disturbances. 

The  sexsory  or  pseudo-tabetic  type  of  multiple  neuritis  is 
caused  less  often  by  alcohol  and  more  often  relatively  by  the  me- 
tallic and  infectious  poisons.  The  general  course  is  much  like 
that  of  the  paralytic  form,  but  there  is  less  paralysis,  and  on  the 
other  hand  there  are  more  of  the  burning,  tearing  pains,  a  greater 
degree  of  anaesthesia,  with  a  very  decided  muscular  anaesthesia 
causing  symptoms  of  a  subacute  locomotor  ataxia.  The  paresis, 
muscular  wasting,  trophic  changes,  such  as  shedding  of  the  epi- 
dermis and  electrical  reactions,  serve  to  distinguish  the  disease.  A 
double  facial  paralysis  somethnes  complicates  this  type. 

Exdemic  and  Epidemic  Types  {Beri-heri  or  Kakke,  Igni- 
pedites,  Acrodynia^  Malarial  Multiple   JYeu  r  it  is). —Beri-heri  or 


DISEASES   OF   THE   PERIPHERAL.  NERVES.  75 

endemic  multiple  neuritis  is  seen  in  this  country  rarely,  and 
only  by  accident.  Beri-beri  is  the  Indian  name ;  kakke,  mean- 
ing "the  leg  disease,''  is  its  Ja,panese  name.  Ignipedites  is  a 
name  given  by  Indian  physicians  to  iDrobably  the  same  disease. 
French  physicians  gave  the  name  of  "  acrodynia  "  to  an  epidemic 
disease  which  prevailed  in  France  and  the  Crimea  in  the  early 
part  of  this  century.  It  was  probably  multiple  neuritis.  There 
are  various  types  of  this  disease,  in  some  of  which  the  neuritic 
symptoms  seem  subordinate  to  those  of  other  organs.  The  forms 
described  by  Scheube  and  Taylor  are ; 

The  acute  pernicious,  the  acute  or  subacute  benign,  the  atro- 
phic or  dry,  and  the  dropsical  or  wet. 

The  symptoms  generally  resemble  those  of  multiple  neuritis, 
as  already  described,  plus  oedema,  extensive  serous  effusions, 
and  gastro-intestinal  disorders.  The  paralysis  affects  esi^ecially 
the  lower  extremities,  but  in  beri-beri  there  seems  to  be  an  espe- 
cial tendency  also  to  involvement  of  vasomotor  and  visceral 
nerves. 

Malarial  Multiple  Neuritis.— -Jamaica  seems  to  be  the  only 
place  in  which  the  malarial  poison  produces  an  endemic  neuritic 
paralysis  (Strachan),  and  the  causation  in  these  cases  is  not  yet 
demonstrated.  Dr.  Strachan"s  description  of  the  symptoms  of 
what  he  terms  malarial  peripheral  neuritis  shows  It  to  be  quite 
extensive,  often  involving  trunk  and  cranial  nerves,  and  accom- 
panied with  much  x^ain  and  wasting.  Cramps  and  skin  eruptions 
are  often  noted,  complications  that  do  not  occur  in  the  ordinary 
types. 

2.  Acute  Peris^icious  Multiple  Neuritis.— There  is  a  form 
of  multiple  neuritis  which  comes  on  suddenly,  progresses  rapidl^^, 
and  causes  death  in  a  few  days  or  weeks.  These  cases  usually  show 
the  ordinary  symptoms  of  neuritic  paralysis,  w^ith  final  involve- 
ment of  the  cardiac  and  respiratory  nerves,  causing  death.  The 
agent  in  these  cases  is  apparently  of  the  nature  of  sepsis.  The 
neuritis  is  interstitial  and  hemorrhagic.  Other  cases  of  acute  per- 
nicious multiple  neuritis  take  the  form  of  acute  ascending  or 
Landry's  paralysis.  Here  there  are  few  sensory  symptoms,  no 
electrical  changes  or  atrophy.  The  disease  is  due  to  an  infectious 
poison  which  overwhelms  the  system  before  it  has  time  to  set  up 
any  inflammation  or  organic  change. 

Pathology. — In  multiple  neuritis  the  disease  affects  the  per- 
iphery of  the  nerves  most,  and  extends  up,  very  rarely  reaching 
the  roots.  The  anterior  tibial  and  musculo-spiral  nerves  on  the 
two  sides  are  oftenest  and  most  diseased. 

The  process  when  mild  in  grade  resembles  a  secondary  degen- 
eration following  section  of  the  nerve.  In  severer  cases  there  is 
evidence  of  interstitial  inflammation  as  w^ell  as  degeneration. 


76 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


This  process,  however,  varies  in  degree  at  different  points  of  the 
nerve's  course.  Hence  it  has  been  called  segmental  or  dissemi- 
nated neuritis.  In  some  of  these  cases  and  in  all  acute  perni- 
cious cases  there  is  still  more  interstitial  inflammatory  change; 
small  hemorrhages  occur,  exudation  takes  place,  and  collections 
of  leucocytes  about  the  vessel  walls  and  among  the  nerve  fibres 
are  seen.  The  muscles  supplied  by  the  diseased  nerves  undergo 
atrophy.     This  is  usually  simple   and  non-inflammatory.    But 


Fig.  44.— Longitudinal  Section  of  a  Nerve  in  ^Multiple  Neuritis,  showing: 
rich  proliferation  of  nuclei  (Ley den).  The  process  here  is  inflammatory  as  well 
as  degenerative. 


sometimes  there  is  an  interstitial  myositis  with  exudation  com- 
pressing the  fibres  (Senator). 

The  spinal  cord  is,  as  a  rule,  healthy,  or  presents  minor  and 
secondary  changes. 

It  will  be  seen,  therefore,  that  in  multiple  neuritis  there  may 
be :  (1)  Simple  degeneration ;  (2)  degeneration  with  some  evidences 
of  interstitial  neuritis  (degenerative  neuritis) ;  (3)  decided  intersti- 
tial neuritis  with  deger.eration  of  nerve  fibres. 

The  changes  occurring  in  nerve  degeneration  have  been  de- 
scribed. In  the  second  class  of  cases— degenerative  or,  as  it  is 
sometimes  called,  parenchymatous  neuritis— naked-eye  changes 
rarely  occur.  Under  the  microscope  many  of  the  nerve  fibres  are 
found  to  have  disappeared;  there  is  increase  in  the  connective 
tissue  and  hyperjemia.     The  vessel  walls  are  usually  thickened. 


DISEASES   OF   THE   PERIPHERAL  NERVES. 


77- 


The  mast  cells  of  Ebrlich  are  seen,  indicating  excessive  connective- 
tissue  activity. 

Diagnosis. — Multiple  neuritis  must  be  diagnosticated  from 
diffuse  or  transverse  myelitis,  anterior  poliomyelitis,  locomotor 
ataxia,  spinal  meningitis,  and  haemorrhage  and  Landry's  paraly- 
sis. Practically,  diffuse  myelitis  is  the  disorder  from  which  it  has 
oftenest  to  be  distinguished.     From  this  it  is  recognized  first  by 


/.■/' 


<-^,  ?--=^ 


^'~ 


Fig.  45. 


-Diphtheritic  Neuritis,  Chiefly  Interstitial  (Siemerling);    v\ith 
secondary  degeneration. 


investigating  the  cause  and  onset.  Neuritis  begins  more  slowly 
and  with  sensory  prodromata;  it  affects  the  legs  and  feet, 
especially  the  extensors,  and  if  it  ascends  it  skips  the  hips  and 
trunks  and  attacks  the  forearms.  There  is  more  muscular 
atrophy  than  in  myelitis;  the  knee  jerks  are  absent.  It  pro- 
gresses more  slowly,  and  after  four  or  eight  weeks  gradually 
regresses.  Electrical  degeneration  reactions  are  more  varied 
and  decided.  There  are  tenderness  over  the  muscles  and  nerves 
and  peculiar  burning,  darting  pains.  The  cutaneous  anes- 
thesia, if  present,  is  not  so  extensive  and  complete,  as  a  rule,  while 
muscular  anaesthesia  is  more  decidedly  marked.     There  is  very 


78  DISEASES   OF  THE   NERVOUS   SYSTEM. 

rarely  involvement  of  the  sphincters,  or  bed-sores.  There  may 
be  belt-like  constrictions  felt  round  the  extremities,  but  not 
around  the  waist.  The  gradual  improvement  of  the  paralysis 
and  atrophy  and  eventual  recovery  confirm  the  diagnosis  of 
neuritis.  The  presence  of  neuritis  of  the  cranial  nerves  would 
strengthen  the  theory  of  a  neuritis. 

From  poliomyelitis  it  is  distinguished  by  the  presence  of  pain 
and  other  sensory  symptoms,  the  early  fall  in  galvanic  irritabUity, 
the  age  of  the  patient,  and  the  etiology. 

From  locomotor  ataxia,  neuritis  is  distinguished  by  its  more 
rapid  onset,  the  presence  of  paralysis  and  atrophy  of  muscles, 
paresis,  with  degeneration  reactions,  and  the  absence  of  involve- 
ment of  the  organic  centres. 

Spinal  hemorrhage  usually  leads  soon  to  a  secondary  diffuse 
myelitis  easily  distinguishable  from  neuritis  by  the  characters 
above  given.  Here  there  is  also  usually  pain  in  the  back.  Spinal 
meningitis  is  associated  with  characteristic  pain,  tenderness,  and 
stiffness  along  the  back.  Acute  ascending  joaralysis  in  its  typical 
form  shows  but  very  slight  sensory  disorders,  and  no  wasting  or 
change  in  electrical  irritability. 

The  complication  of  multiple  neuritis  and  myelitis  or  posterior 
sclerosis  is  possible,  but  is  very  rare.  In  the  former  case  the 
ordinary  symptoms  of  myelitis  are  added  to  those  of  neuritis. 
In  locomotor  ataxia  there  is  often  some  nerve  degeneration  and 
occasionally  neuritis.  The  nerve  degeneration  probably  only 
causes  slow  atrophic  changes  and  iDaresis;  the  neuritis  causes 
pains,  anaesthesia,  skin  eruptions,  and  local  troj^hic  disorders. 

Prognosis. — Alcoholic  multiple  neuritis  is  a  serious  disease, 
because  of  its  associated  conditions.  Nearly  one-half  of  my  pa- 
tients have  died,  mainly  because  they  continued  the  use  of  alco- 
hol after  paralysis  appeared.  They  do  not  die  of  neuritis,  but  of 
alcoholism  or  of  phthisis.  Other  forms  of  neuritis  rarely  cause 
death.  The  great  majority  recover  almost  completely.  It  may 
be  from  six  months  to  two  years  before  all  symptoms  disappear. 
The  average  time  is  about  a  year. 

Treatment.— The  patient  needs,  first  of  all,  rest  in  bed.  The 
limbs  are  often  extremely  tender  and  the  patient's  pains  ex- 
cruciating. To  relieve  these  the  legs  may  be  painted  with 
menthol  and  enveloped  in  cotton  batting.  In  other  cases  flan- 
nels wrung  out  in  hot  water  and  renewed  every  two  hours  give 
relief.  Internally  phenaeetin,  antipyrine,  salicylate  of  soda,  may 
be  given.  In  the  early  stages,  salicylate  of  soda  in  doses  of  gr.  xx. 
every  two  or  three  hours  should  be  administered.  If  there  is  a 
great  deal  of  depression  from  alcoholic  poisoning,  strychnia  gr. 
^V  Q-  3  h.  and  aromatic  spirits  of  annnonia,  3  ss.  q.  3  h.,  should  be 
used.    Nitrate  of  silver  is  also  useful  in  the  early  stage. 


DISEASES   OF   THE   PERIPHERAL  NERVES.  79 

After  the  acute  stage  is  passed  the  labile  galvanic  current  oc- 
casionally interrupted  may  be  applied,  2  to  6  ma.  for  ten  minutes 
three  times  weekly.  Later,  by  the  sixth  week,  the  faradic  current, 
massage,  and  careful  exercise  should  be  given.  At  this  time  or 
earlier  (third  Aveek),  strychnia,  iodide  of  potassium,  arsenic,  and 
tonics  may  be  given.  In  old  cases  in  which  a  great  deal  of 
paralysis  and  contracture  hav^e  occurred,  forcible  extension  of  the 
limbs,  the  use  of  splints  and  rubber  muscles,  are  needed.  With 
patience  and  perseverance  the  worst  cases  can  eventually  be 
brought  to  a  complete  recovery. 

CoMPLiCATi^s^G  Forms  of  Neuritis  axd  Neuritic  Degen- 
ERATioi!^. — Neuritis  and  neuritic  degeneration  complicate  many 
diseases,  but  they  especially  mark  and  modify  subacute  and 
chronic  rheumatism,  locomotor  ataxia,  diabetes,  paralysis  agitans, 
wasting  diseases,  and  old  age. 

A  neuritic  degeneration  almost  always  affects  the  nerves  in 
the  neighborhood  of  an  old  rheumatic  joint.  The  chief  result  of 
this  is  to  produce  wasting  and  some  paresis  of  the  muscles  mov- 
ing the  joint  (Pitres  and  Vailtard).  The  iDrocess  is  a  reflex  atrophy 
(see  Arthritic  Muscular  Atrophy). 

In  locomotor  ataxia,  parenchymatous  degeneration  is  very 
often  present.  It  does  not  produce  the  cardina.1  symptoms  of  this 
disease.  It  does,  however,  cause  some  of  The  anaesthesia,  parses- 
thesia,  muscular  atrophy,  skin  dystrophies,  and  visceral  crises. 

In  diabetes,  the  neuritis  takes  the  form  of  the  sensory  type  of 
multiple  neuritis,  and  causes  symptoms  like  those  of  locomotor 
ataxia.  The  patient  has  sciatic  pains,  burning  or  numb  feet,  loss 
of  tendon  reflex,  ataxia.    The  upper  extremities  are  rarely  affected. 

I7i  Wasting  Diseases  and  Old  Age. — In  various  wasting  dis- 
eases, such  as  phthisis,  cancerous  cachexia,  long-continued  fevers, 
marasmus,  and  in  senility,  a  simple  parenchymatous  degeneration 
of  nerves,  with  atrophy,  occurs  (Arthaud,  Koster,  Jappa).  The 
symptoms  caused  by  these  changes  are  very  slight.  They  con- 
tribute to  the  weakness  and  wasting.  In  old  age,  the  atrophy  of 
the  nerves  is  one  cause  of  the  lessened  sensibility  and  activity  of 
the  skin  and  its  underlying  muscles, 

MoRVA^^'s  Disease,  Analgesic  Paralysis  with  Whitlow. 
— (Neuritic  type  of  syringo-myelia.) 

This  is  a  very  rare  disease,  characterized  by  a  slowly  progres- 
sive paralysis  and  atrophy  of  the  hands  and  forearms,  with  anal- 
gesia and  painless  whitlows. 

It  occurs  usually  in  young  or  middle-aged  males.  Occupations, 
such  as  handling  fish,  which  involve  exposure  and  trauma,  pre- 
dispose to  the  disease. 

The  symptoms  come  on  slowly,  with,  at  first,  severe  pains  in 
the  arms  and  hands.     The  muscles  of  these  parts  gradually  get 


80  DISEASES   OF  THE   NERVOUS   SYSTEM. 

■weak  and  atrophy.  Ansesthesia  and  analgesia  are  present.  Usu- 
ally there  is  loss  of  pain  and  temperature,  but  not  of  tactile 
sense.  Whitlows  appear  which  are  painless,  and  one  or  more  of 
the  terminal  phalanges  may  necrose.  There  is  usually  a  swelling 
and  hard  oedema  of  the  parts.  Both  upper  extremities  may  be 
affected,  and  sometimes  the  feet  are  also  slightly  involved.  There 
is  sometimes  spinal  curvature.  Hysteria  may  complicate  the  affec- 
tion. The  course  of  the  disease  is  very  chronic,  but  there  may  be 
long  periods  in  which  the  symptoms  are  quiescent. 

Pathological  examinations  always  show  a  neuritis  of  the  parts 
involved  in  the  disease.  In  some  cases  a  syringo-myelia  has  been 
found. 

There  is,  therefore,  a  Morvan's  disease  due  to  syringo-myelia 
and  neuritis,  and  another  type  due  to  a  neuritis  alone. 

The  prognosis,  so  far  as  cure  is  concerned,  is  bad,  but  the  dis- 
ease may  remain  stationary  a  long  time  or  improve. 

The  diagnosis  is  based  on  the  combination  of  paralysis,  atro- 
phy, loss  of  pain  and  temperature  but  not  of  tactile  sense,  and 
whitlows. 

Strychnine  seems  to  have  stopped  the  progress  of  the  malady  in 
one  case.     The  treatment  in  general  is  only  symptomatic. 


FUNCTIONAL  DISORDERS   OF  THE   PERIPHERAL 
NERVES. 

These  are : 

1.  Motor  forms :  tremor,  spasm,  paralysis. 

2.  Sensory  forms :  neuralgia,  parsesthesia. 

3.  Mixed  neuroses. 

1.  Tremor  and  spasm  sometimes  occur  from  peripheral  nerve 
irritation.  The  cause  is  over-use  of  the  limbs,  and  the  symptoms 
are  associated  with  others  belonging  to  the  occupation  neuroses 
(see  p.  468). 

Wakixg  Numbness  (Night  Palsy,  Recumbext  Palsy). 

This  is  a  disorder  characterized  by  a  temporary  paralysis  of  an 
extremity,  with  numbness,  noticed  on  first  waking,  or  after  lying 
down  for  a  time. 

It  is  a  rare  disease  and  little  is  known  of  its  cause.  It  occurs 
in  adults  and  usually  in  the  neuropathic.  Sometimes  evidence 
of  weak  heart  or  poor  innervation  of  the  vessels  is  present. 

The  symptoms  are  much  like  those  caused  by  temporary  com- 
pression of  a  nerve  wlien  the  leg  or  arm  go  to  sleep.  The  paral- 
ysis is  temporary  and  there  is  no  anaesthesia.  It  is  often  very 
obstinate. 


DISEASES   OF   THE   PERIPHERAL  NERVES.  81 

The  treatment  consists  in  giving  strychnine,  mineral  acids,  and 
electricity,  with  occasional  courses  of  bromides;  iron  and  anti- 
rheumatics may  be  needed  in  some  cases. 

2.  Sensory  Neuroses.    Neuralgia. 

i)e/z7?,?fww.— Neuralgia  is  a  functional  disease  characterized  by 
pain  in  the  course  of  a  nerve  or  of  nerves. 

i^or??i5.— Neuralgias  may  be  idiopathic,  t.e.,  developed  sponta- 
neously, or  symptomatic,  due  to  some  known  toxic  influence,  re- 
flex irritant,  or  organic  disease  acting  on  the  nerve.  Thus  a 
central  disease  of  the  nervous  system  or  a  tumor  pressing  on  a 
nerve  may  cause  a  symptomatic  neuralgia.  When,  however, 
there  is  organic  disease  of  the  nerve  itself,  such  as  neuritis, 
the  disease  cannot  be  called  neuralgia.  It  is  often  impossible 
to  draw  the  lines  absolutely. 

Neuralgias  are  divided,  in  accordance  with  their  cause,  into  the 
epileptiform,  hysterical,  reflex,  traumatic,  gouty,  etc. 

Neuralgias  are  also  divided,  in  accordance  with  their  anatomi- 
ical  location,  into  trigeminal,  cervico -occipital,  brachial,  inter- 
costal, lumbar,  crural,  sciatic,  and  visceral. 

Migraine  and  headache  are  not  classed  among  neuralgias. 

Frequency. — Neuralgias  of  all  kinds  make  up  about  ten  per 
cent  of  the  nervous  disorders  for  which  the  neurologist  is  con- 
sulted. The  most  frequent  form  is  the  trigeminal ;  next  in  order 
come  the  sciatic,  intercostal,  cervico-occipital,  lumbo-abdominal, 
brachial,  and  visceral  neuralgias. 

Etiology:  Predisposing  Causes.  —  Neuralgia  never  affects 
young  children,  and,  leaving  out  migraine  and  headache,  it  is 
rarely  met  with  before  the  fifteenth  year.  From  that  time  until 
twenty-five  the  frequency  very  rapidly  increases.  About  one- 
fourth  occur  betw^een  the  ages  of  fifteen  and  twenty-five;  the 
relative  number  then  slowly  decreases  to  the  forty-fifth  year,  when 
there  is  a  rapid  fall.     Neuralgia  is  very  rare  in  old  age. 

Women  are  more  affected  than  men  in  the  proportion  of  five 
to  three  (analysis  of  887  cases).  In  New  York  most  cases  occur  in 
winter,  next  in  the  autumn.  More  cases  occur  in  temperate  cli- 
mates and  in  wet  and  cold  regions. 

Hereditary  influence,  neurotic  constitution,  anaemia  and  de- 
bility, gouty  and  rheumatic  diatheses,  all  predispose  somewhat  to 
the  disease.  The  exciting  causes  can  be  included  under  the  head 
of  toxic  agents,  infections,  exposure,  over-exertion,  emotional 
shock,  and  injuries. 

Local  irritation  of  nerves  may  excite  neuralgia,  direct  or  reflex 
in  kind.  Some  help  in  recognizing  the  reflex  origin  of  neuralgias 
and  other  pains  may  be  gained  from  the  accompanying  dia- 
grams. 

6 


82 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


S>/i7iptoms.— These  will  be  described  in  detail  in  the  chapters 
on  the  special  forms. 

The  dominant  symptom  is,  of  course,  pain.  This  pain  is 
sharp,  dartin^:,  boring,  stabbing,  or  burning  in  character.  It 
comes  on  in  paroxysms  of  great  intensity.  In  the  intervals  there 
may  be  no  pain  or  it  may  be  simply  a  dull  ache.  The  pain  runs 
along  the  course  of  certain  nerves,  it  is  not  confined  neces- 
sarily to  them,  but  may  be  somewhat  diffuse.  Pain  is  increased 
or  brought  on  by  cold  or  heat,  or  xDressure  on  the  attected  part. 


Fig.  4G.— Diagrams  showing  the  Distribution  op  the  Cerebro-Spinal  Strands 
OF  Nerves  and  the  Location  op  Transferred  Pains  and  Neuralgia. 


Area  I. . . 
Area  II. . 
Area  III. 

Area  IV. 
Area  V. . 

Area  VI. 

Area  VII 


Strands  of  Cerebro-Spinal 
Nerves. 


Trif^eminus,  facial,  etc. 

Upper  four  cervical. 

Lower  four  cervical  and 
first  dorsal. 

Upper  si.x  dorsal. 

Lower  six  dorsal  except 
last. 

Twelfth  dorsal,  four  lum- 
bar. 

Fifth  lumbar  aud  five  sa- 
cral. 


Distribution. 


Face  and  its  orifices,  anterior  scalp. 
Occipital  region,  neck. 
Upper  extremities. 

Thoracic  wall. 

Abdominal  wall,  upper  lumbar,  upper 

lateral  thi^^h  surface. 
Lumbar  region,  upper  gluteal,  ante- 
rior and  inner  thigh  and  knee. 
Lower  gluteal,  posterior  thigli,  leg. 


DISEASES   OF   THE   PERIPHERAL   NERVES.  83 

The  skin  and  nerves  are  sometimes  tender  or  even  exquisitely 
sensitive.     Firm  pressure,  however,  is  usually  not  painful. 

In  about  half  the  cases  of  long  standing,  tender  x^oi ids  may  be 
found  which  correspond  to  the  exit  of  nerves  from  a  bony  canal 
or  the  substance  of  a  muscle  or  fascia.  In  rare  cases  there  is  ten- 
derness over  the  spine  corresponding  to  the  point  where  the 
affected  nerves  arise. 

Besides  feelings  of  pain,  there  is  often  a  sense  of  numbness, 
coldness,  tingling,  or  heaviness  of  the  limb.  Vasomotor,  secre- 
tory, and  trophic  disturbances  may  occur ;  but  when  these  are 
pronounced,  one  must  suspect  neuritis  or  an  organic  central  dis- 
ease. Muscular  spasm  is  sometimes  present;  more  rarely  there 
is  some  muscular  weakness. 

The  paroxysms  of  pain  may  intermit  regularly ;  sometimes  they 
come  on  every  day,  at  the  same  hour.  They  are  apt  to  be  worse 
at  night. 

The  attacks  of  the  disease  often  run  a  course  of  several  weeks 
or  months,  and  in  some  forms  they  last  for  years. 

Pathology. — Many  cases  that  used  to  be  called  neuralgia  are  now 
known  to  be  forms  of  neuritis,  e.g.,  sciatica  and  brachial  neural- 
gia. Other  forms  are  sometimes  due  to  impaired  nutrition  of  the 
nerves  from  an  obliterating  arteritis  (tic  douloureux) ;  still  others 
are  due  to  the  irritation  of  nerves  from  the  diathetic  poison  of 
gout,  rheumatism,  and  diabetes,  or  to  extrinsic  poisons,  such  as 
alcohol,  lead,  and  arsenic.  In  these  cases  the  sensory  nerves  of 
the  nerve  sheaths  (nervi  nervorum)  are  affected.  There  remain 
many  cases  in  which  the  trouble  shifts  from  one  locality  to  an- 
other, or  in  which  no  special  local  or  general  irritation  can  be 
discovered.  In  these  cases  we  assume  that  the  pathogenic  focus 
is  the  spinal  ganglia  or  the  sensory  cells  of  the  posterior  horns 
of  the  spinal  cord.  Lesions  and  irritations  of  the  sensory  path 
above  the  sensory  cells  referred  to  rarely  cause  pain. 

There  are  some  forms  of  neuralgia  which  may  be  called  "  rem- 
iniscent ''  or  "  hallucinatory.'"  The  patient,  who  is  an  impression- 
able and  sensitive  person,  has  had  a  genuine  cause  for  neuralgic 
pains;  but  this,  after  lasting  some  time,  has  ceased,  while  the 
painful  impressions  continue  to  remain  in  the  cerebral  cortex. 
The  neuralgia  is  a  morbid  habit  of  feeling  pain.  Such  neuralgias 
are  promoted  often  by  the  use  of  morphine. 

The  Diagnosis.— This  depends  on  the  fact  that  neuralgic  pains 
are  shifting,  paroxysmal,  follow  the  course  of  nerves,  are  accom- 
panied often  with  tender  points  and  not  accompanied  with  signs 
of  organic  nerve  disease,  such  as  paralysis  and  anaesthesia  and 
tenderness  over  the  nerve  trunks.  Thermic  sensations  of  burning 
or  coldness  are  rarely  neuralgic,  but  are  due  to  neuritis. 

The  2)rognosis\s  good,  except  for  the  reminiscent  neuralgias, 


84  DISEASES   OF  THE   NERVOUS   SYSTEM. 

the  neuralgias  of  hysterical  and  neurasthenic  persons,  who  are 
thoroughly  ananiiic,  debilitated,  and  broken  down  morally  and 
physically.  The  neuralgias  of  the  degenerative  period  of  life 
are  also  very  obstinate. 

The  treatment  will  be  discussed  under  special  heads. 

The  Parjesthesic  Neurosis  (Parjesthesia,  JN'umb  Hands). 

This  is  a  not  uncounnon  disorder,  characterized  by  very  per- 
sistent symptoms  of  numbness,  formication,  or  burning,  with 
little  or  no  jmin,  and  with  or  without  motor  weakness.  It  is  a 
trouble  allied  to  the  waking  numbness  just  described. 

Etiologij.—The  disease  occurs  in  adult  life,  and  oftenest  at  or 
after  middle  life.  Women  are  oftenest  affected,  and  especially 
those  of  nervous  temperament,  with  dyspeptic  and  rheumatic 
tendencies.  The  symptoms  are  not  seen  in  children  or  in  the  aged. 
They  are  more  marked  in  the  warmer  season,  and  women  who 
wash  a  good  deal  are  somewhat  more  subject  to  them.  The  dis- 
order is  more  frequent  in  cities. 

&i/niptoms. — The  patients  have  feelings  of  numbness,  prickling, 
heaviness,  usually  in  both  hands,  extending  a  little  way  up  the 
forearm.  The  sensations  are,  as  a  rule,  diffuse,  but  may  follow 
the  distribution  of  a  nerve,  especally  the  ulnar.  In  other  cases 
the  numbness  is  sharply  limited  to  the  finger-tips  or  the  second  and 
third  phalanges.  There  is  no  actual  pain  or  tenderness,  nor  is 
there  any  anesthesia,  cutaneous  or  muscular.  Instead  of  or  with 
the  numbness  there  may  be  burning  sensations,  especially  felt  in 
the  palms  or  soles.  There  is  often  a  slight  degree  of  paralysis, 
but  rarely  any  decided  vasomotor  or  trophic  changes.  The  symp- 
toms exacerbate,  being  worse  at  certain  periods  of  the  day,  usu- 
ally in  the  morning.  Tliey  may  increase  at  night  and  prevent 
sleep. 

The  arms  are  oftener  affected  than  the  lower  extremities ;  and 
the  disease  never  takes  a  hemiplegic  form,  though  one  arm  may 
be  alone  involved.  The  scalp  and  ears  may  be  involved,  though 
always  in  a  minor  degree,  the  patient  complaining  of  sensations 
of  heat,  prickling,  flushing,  and  vertex  pressure.  Sometimes  the 
knee  jerk  disappears.  The  symptoms  cause  a  condition  of  men- 
tal unrest  and  nervousness  which  add  to  the  sufferings  materi- 
ally. Evidences  of  overwork,  of  dyspepsia  and  constipation,  of 
antemia,  or  of  muscular  rheumatism  will  generally  be  found. 
The  urine  is  usually  rather  light  in  color  and  specific  gravity 
(1010  to  1018),  slightly  cloudy,  with  excess  of  phosphates  and  oc- 
casional excessive  discharges  of  urates. 

Pathology. — The  pathology  is  based  upon  the  similarity  of  the 
symptoms  to  those  in  mild  or  incipient  cases  of  multiple  neuritis 


DISEASES   OF  THE   PERIPHERAL  NERVES.  85 

and  upon  the  effects  of  drugs  in  relieving  symptoms.  It  is  be- 
lieved that  the  peripheral  nerves  are  being  irritated  by  some 
poison  circulating  in  the  blood.  Co-operating  with  this  are  nerves 
naturally  over-irritable,  or  made  so  by  anaemia,  hypertemia,  and 
exposure  to  cold. 

Diagnosis.— This  disease  is  to  be  distinguished  from  hysteria, 
neurasthenia,  and  central  organic  diseases  of  cord  or  brain.  In 
hysteria  the  symptoms  are  less  diffuse,  regular  and  bilateral, 
while  some  anaesthesia  is  rarely  absent.  Parsesthesise  are  very 
common  in  neurasthenia,  and  in  some  cases  here  they  are  due,  no 
doubt,  to  peripheral  irritation.  In  neurasthenia,  the  parsesthesise 
are,  however,  generally  in  one  extremity,  less  diffuse  and  as  a  rule 
more  temporary.  There  is  no  motor  weakness,  and  the  head  and 
spine  are  usually  complained  of  more  than  the  arms  or  legs. 
Waking  numbness  and  night  palsy  are  intermittent  disorders, 
disappearing  within  a  short  time  after  waking  or  rising  from  a 
recumbent  posture.  The  numbness  that  is  felt  with  digiti  mortui 
and  Raynaud's  disease  is  accompanied  with  spasm  of  the  blood- 
vessels and  whitening  of  the  fingers. 

Prognosis  and  Course. — The  disease,  if  not  treated,  runs  a 
course  of  several  months,  with  some  intermissions  and  relapses. 
It  may  disappear,  to  return  the  next  year.  It  never  progresses  to 
any  serious  condition,  and  is  in  almost  all  cases  eventually  cured. 

Treatment. — The  patient  should  receive  alkalies,  with  bro- 
mides, pepsin,  iron,  and  strychnia.  The  f aradic  current,  massage, 
and  stimulating  liniments  are  useful.  Rest  and  removal  from  ex- 
citing causes,  such  as  exposure,  are  also  indicated. 

3.  Neuroses  of  Mixed  Origin  Affecting  the  Extremities 
(Acro-Neuroses). 

There  are  certain  nervous  disorders  which  affect  the  extremi- 
ties. They  involve  the  motor,  sensory,  vasomotor,  secretory,  and 
trophic  nerves  in  various  degrees.  They  are  sometimes  of  central 
and  sometimes  of  peripheral  origin ;  but  as  the  pathology  is  lit- 
tle known,  they  are  best  given  a  clinical  classification  and  placed 
under  the  head  of  peripheral  diseases. 

The  acro-neuroses  here  considered  are :  Raynaud's  disease  and 
digiti  mortui.     Podalgia,  luxation  neuralgia.     Erythromelalgia. 

Symmetrical  Angio-Neurotic   Gangrene,   or  Raynaud's 
Disease.    (Abortive  Form  Known  as  Digiti  Mortui.) 

Symmetrical  gangrene  or  Raynaud's  disease  is  a  rare  affection 
characterized  by  spasm  of  the  vessels  of  the  extremities,  coldness, 
pallor,  waxiness  of  fingers  or  toes,  or  by  blueness,  mottling,  swell- 


86 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


ing,  pain,  followed  often  by  a  dry  gangrene  of  some  of  the  fingers 
or  toes. 

Etiology. — The  disease  occurs  usually  in  children  and  young 
adults.  Women  are  affected  oftener  than  men.  Anaemia,  and 
chlorosis,  and  neurasthenic  states  predispose  to  it.  Malarial  in- 
fection, acute  infectious  fevers,  menstrual  disorders,  fright,  oc- 
cupations that  lead  to  exposure,  such  as  washing,  are  causative 
factors.     Diabetes  and  syphilis  are  also  put  down  as  causes. 

The  disease  comes  on  rather  suddenly  and  affects  oftenest  two 
or  three  fingers  of  both  hands.  In  its  early  and  mild  degree  there 
is  simply  a  coldness,  numbness,  and  waxy  pallor  of  the  fingers. 
The  skin  looks  shrunken.     There  is  shght  anaesthesia.     They  feel 


Fig.  47.— Hand  and  Foot   in   the  Ga>-grenous  Stage  of  Raynaud's  Disease. 


as  if  dead.  After  a  few  hours  this  passes  away,  but  returns  again 
and  may  finally  become  an  almost  constant  condition.  Begin- 
ning in  one  or  two  fingers,  it  may  finally  involve  all.  The  toes, 
tip  of  the  nose,  and  ears  may  be  similarly  affected,  though  this  is 
rare  in  the  milder  form.  Exposure  to  cold,  even  slight,  is  the 
common  excitant  of  this  form  of  the  trouble,  which  is  commonly 
known  as  "  digiti  mortui."  "  dead  fingers,"  or  "  local  syncope." 

In  severer  grades  the  fingers  become  blue,  swollen,  and  there 
are  burning  sensations  and  much  pain,  but  no  anaesthesia.  This 
condition  is  known  as  that  of  "  local  asphyxia,"  and  it  is  usually 
followed  by  gangrene. 

In  the  gangrenous  stage  small  blisters  appear  on  the  distal 
phalanges,  which  fill  with  bloody  serum,  then  dry  up,  and  beneath 


DISEASES   OF   THE   PERIPHERAL  NERVES.  87 

the  scab  ulceration  begins,  which  is  shallow  and  soon  heals,  leav- 
ing a  scar.  The  process  then  stops.  In  very  rare  cases  the  whole 
tip  of  the  finger  or  toe,  including  the  bone,  becomes  involved.  The 
process  as  stated  may  attack  the  ears,  lips,  tongue,  and  even  parts 
of  the  trunk.  Along  with  this  gangrenous  process  there  is  often  a 
hsematuria. 

The  dead-finger  trouble  may  last  but  a  few  days  or  weeks,  or 
it  may  continue  for  months.  The  gangrenous  stage  lasts  about 
three  weeks.  It  lasts  longer  if  it  comes  on  in  one  finger  after  the 
other.     The  disease  is  one  of  months,  and  it  is  liable  to  recur. 

The  diagnosis  must  be  made  from  senile  gangrene,  frost-bite, 
ergot-poisoning,  alcoholic  neuritis,  endarteritis,  and  obstruction 
of  nutrient  vessels. 

Pathology. — A  neuritis  has  been  found  in  some  cases  of  so- 
called  Raynaud's  disease,  but  this  is  secondary.  In  a  few  other 
cases  there  has  been  found  an  obliterating  endarteritis  (Jacoby). 

The  trouble  is  in  some  cases  apparently  functional  and  due  to 
the  combination  of  an  over-sensitive  nervous  system  and  some 
irritant,  such  as  impoverished  blood,  malaria,  or  other  toxic  agent, 
which  causes  spasm  of  the  peripheral  vessels. 

Prognosis. — The  cases  usually  get  well.  In  only  the  rarest  in- 
stances has  death  occurred,  and  then  from  some  complication. 

Treatment. — Galvanism  to  the  spine  and  limbs,  warm  applica- 
tions, anodynes,  tonics,  are  indicated.  Nitroglycerine,  the  iodides^ 
chloral  may  be  tried.     No  specific  is  known. 

Paixs  i:?^  the  Feet  of  Various  Origin  (Podalgia). 

1.  Pains  of  diathetic,  toxic,  or  neuralgic  origin. 

2.  Pains  of  reflex  origin.  i| 

3.  Pains  of  mechanical  origin. 

1.  Pedal  pains  occur  in  gout,  rheumatism,  lithaemic  states, 
sjq^hilis,  tabes,  chronic  alcoholism,  and  diabetes.  The  pains  of 
latent  gout,  according  to  Anstie,  are  generally  located  in  the  dor- 
sum of  the  foot.  Those  of  chronic  alcoholism  have  been  observed 
to  occur  in  the  wrists  and  ankles.  Those  of  lithsemia  are  usually 
in  the  heels.  In  syphilis  a  node  can  generally  be  discovered.  A 
difTerential  diagnosis  is  therefore  possible. 

Erythromelalgia  {red  neuralgia  of  the  feet,  congestive  neu- 
ralgia) is  a  disease  aff'ecting  the  feet  chiefly,  and  characterized  by 
burning  pains  and  congestion  of  the  parts. 

The  disease  occurs  usually  in  men  in  middle  life,  after  a  low 
fever  or  severe  physical  exertion  afoot. 

The  disease  begins  in  the  ball  of  the  foot  or  the  heel  with  a 
pain,  which  Is  worse  at  night.  It  increases  until  nearly  the  whole 
sole  in  the  distribution  of  the  plantar  nerve  is  involved,  and  the 


88  DISEASES   OF  THE   NERVOUS   SYSTEM. 

pain,  though  worse  at  night,  is  ahuost  continuous.  It  is  much 
increased  by  exertion,  the  feet  become  very  tender,  and  standing 
or  walking  is  most  painful.  Meanwhile  there  has  developed  with 
the  pain  a  flushing  of  the  part  upon  exertion.  In  bad  cases  the 
parts  most  atiected  are  continuously  marked  by  a  dull,  dusky, 
mottled  redness. 

The  hands  may  be  slightly  affected.  Slight  injuries  may  cause 
blisters  and  even  ulcerations.  The  congestion  usually  disappears 
in  the  horizontal  position,  and  this  also  relieves  the  pain.  The 
symptoms  are  worse  in  warm  weather.  The  disease  is  very  chronic 
and,  though  not  dangerous  to  life,  makes  life  very  miserable. 

Patliology.—ln  the  cases  of  erythromelalgia  as  described  by 
Mitchell  and  others,  there  is :  (1)  A  vasomotor  neurosis;  (2)  a  plan- 
tar neuritis;  and  (8),  in  rare  instances,  spinal  cord  disease. 

The  diagnosis  must  be  made  from  alcoholic  and  gouty  parses- 
thesia,  podalgia,  local  disease  of  bone  and  ligaments  and  from 
reflex  pains. 

Treatment.— WQYSition  of  the  feet  and  applications  of  cold 
give  temporary  relief.  Faradization  has  sometimes  given  help ; 
oftener  it  has  not.  There  is  nothing  known  which  gives  perma- 
nent relief.  The  physician  must  rely  ujDon  rest,  bandaging,  cold, 
anodyne  applications,  hydrotherapy  and  tonics.  The  salicylates, 
turpentine,  and  mineral  acids  with  strychnia  may  be  given. 

2.  Reflex  or  referred  pains  in  the  feet  are  very  common.  The 
cause  is  usually  some  form  of  irritation  of  the  genito-urinary 
tract,  such  as  gonorrhoea,  stricture  of  the  urethra,  vesical  calcu- 
lus, cystitis,  or  renal  calculus.  It  may  be  a  misplaced  or  pregnant 
uterus. 

3.  Pains  of  mechanical  origin : 

(a)  Morton's  neuralgia. 

{h)  Tarsalgia,  or  policeman's  disease. 

(a)  MoRTOX's  NEURALGIA,  SO  Called,  is  a  neuralgia  affecting 
the  metatarso-phalangeal  joint  of  the  third  and  fourth  toes,  and 
is  due,  it  is  thought,  to  a  slight  luxation,  with  consequent  joressure 
on  a  digital  branch  of  the  external  plantar  nerve.  It  sometimes 
affects  other  toes,  however.  It  is  not  always  due  to  a  luxation. 
Incipient  fiat-foot  may  cause  it,  and  I  have  seen  a  typical  case  in 
a  pregnant  woman,  disappearing  after  confinement.  The  trouble 
occurs  generally  in  Avomen,  and  if  there  is  a  luxation  the  cause  is 
external  injurj^  or  shoe-pressure.  Treatment  is  not  very  satis- 
factory. It  should  be  directed  to  giving  rest  to  the  foot,  and  the 
avoidance  of  lateral  pressure  on  the  joints  by  wearing  a  broad- 
«oled  shoe  with  support  to  the  arcli  of  the  foot.  Support  may 
also  be  given  by  a  broad  flannel  bandage.  Amputation  of  the 
toe  has  cured  one  case. 

ip)  Tarsalgia  {policeman's  disease)  is  a  neuralgic  affection, 


DISEASES   OF   THE  PERIPHERAL  NERVES.  89 

due  probably  in  most  cases  to  an  incipient  flattening  of  the  foot 
and  stretching  of  the  plantar  ligaments.  Some  have  ascribed  it  to 
a  deep-seated  contusion  of  the  adipose  cushion  covering  the  os 
calcis.  Probably  the  condition  varies  somewhat  in  difT3rent  cases. 
It  is  observed  in  persons  who  have  been  in  the  habit  of  going 
barefoot,  and  have  then  gone  into  the  army  or  taken  civil  posi- 
tions obliging  them  to  stand  or  walk  a  great  deal. 

It  occurs  in  the  policemen  of  Paris,  and  but  few  cases  have 
been  seen  in  this  country.  This  is  due  to  the  difference  in  the 
shoes  and  in  the  gait  of  American  and  Parisian  guardians  of  the 
peace.     The  name  tarsalgia  was  given  by  Duchenne. 

Treatment,  medical  or  surgical,  seems  to  do  little  for  the  dis- 
order, which  is  very  chronic.  Patients  are  better  in  cold  weather, 
and  when  resting  the  feet.  Leeches,  the  cautery,  the  iodides, 
and  broad  shoes  with  rubber  heels  are  serviceable. 


Tumors  of  x^erves. 

These  consist  of : 

1.  Nerve  hyperplasia. 

2.  True  neuromata.     (Single.      -  Tvr  t*   '    . 
o    -r.  1  X       h  (  Malignant. 

3.  False  neuromata.    \  t.,  i. .   ■,      ,  -d     • 

;  Multiple,  i  Benign. 

1.  Hyperplasia  or  hypertrophy  of  nerve  trunks  is  very  rare. 
Generally  the  increase  in  size  is,  in  fact,  due  to  increase  of  the 
interstitial  connective  tissue.  Sometimes  there  is  an  increase  in 
the  number  of  fibres  and  thickening  of  the  myelin  sheath. 

2.  Trice  neuromata  are  also  very  rare,  and  occur  almost  exclu- 
sively on  spinal  nerves.  In  some  there  is  an  increase  in  medul- 
lary fibres ;  in  others  only  an  increase  of  non-medullated  fibres, 
i.  e. ,  only  the  axis  cylinders  and  neurilemma  increase.  They  occur 
either  singly  or  multiply.  Multiple  neuromata  are  generally  of 
a  neuro-fibromatous  character. 

Neuro-flbromata  when  multiple  may  affect  the  subcutaneous 
nerves  and  form  growths  known  £i&  fibroma  molluscum. 

Nerve  fibres  united  in  a  mass  by  hyperplastic  connective  tissue 
form  what  are  called  plexiform  neurofihromata.  Multiple  neu- 
romata may  be  true  neuromatous  growths. 

True  neuromata  are  usually  small,  ranging  from  1  cm.  (two- 
fifths  of  an  inch)  to  6  cm.  in  diameter.  They  may  be  much  smaller 
or  larger. 

Neuromata  are  usually  few  in  number,  or  at  least  there  is  only 
a  local  multiplicity  of  tumors.  Multiple  (true)  neuromata  may, 
however,  be  very  numerous.  Gowers  estimates  in  one  case  that 
as  many  as  one  thousand  were  present.  Even  larger  numbers  have 
been  observed. 


90  DISEASES   OF   THE   KERVOUS   SYSTEM. 

3.  False  Neuromata.— This  term  is  applied  to  the  various  nerve 
tumors  in  which  a  fibroma,  myxoma,  ghoma,  sarcoma,  carci- 
noma, or  syphiloma  grows  upon  or  in  the  nerve,  Fibro-neuroma 
is  the  most  common  form ;  glio-neuroma  has  been  observed  on  the 
auditory  nerve.  Syphiloma  occurs  only  on  the  intra-cranial  or 
intra-spinal  nerves.  Carcinoma  of  nerves  may  be  primary,  but  is 
generally  secondary,  and  is  of  scirrhous  or  medullary  type,  rarely 
the  colloid.  Leprous  neuritis  sometimes  forms  neuro-fibromatous 
swellings. 

Tuhercula  dolorosa  are  simply  small  false  neuromata  situated 
subcutaneously  on  the  ends  of  the  sensory  nerves.  They  vary 
much  in  histological  structure. 

Malignant  Neuromata. — A  few  cases,  about  thirty  in  all,  have 
been  observed  of  multiple  malignant  neuromata.  Trauma  and 
hereditary  influence  are  the  etiological  factors.  The  great  nerve 
trunks  are  of tenest  affected,  the  median,  sciatic,  and  crural  rank- 
ing first.  The  tum.ors  start  from  the  perineurium;  they  are  at 
first  spindle-shaped,  and  may  grow  very  large.  Sarcomatous  cells 
are  of tenest  found  in  them ;  but  they  may  be  myxomatous,  fibrom- 
atous,  or  mixed. 

Etiology. — Three  general  causes  exist  for  the  production  of 
neuromata,  viz.  •  1.  A  hereditary  or  a  neuropathic  predisposition ; 
this  tends  to  cause  the  true,  the  multiple,  and  the  plexif  orm  neuro- 
mata. 2.  Injuries,  surgical  operations;  these  cause  especially  the 
fibro-neuromata  of  which  the  amputation  neuroma  is  an  example. 
3.  Diathetic,  e.g.^  tubercular,  influences  and  whatever  produces  the 
various  tumor  formations,  sarcoma,  carcinoma,  form  the  third 
etiological  factor.  Neuromata  of  the  plexiform  type  are  often 
congenital.  Multiple  neuromata  may  develop  early  in  life.  Men 
are  far  more  subject  to  multiple  neuromata  than  women. 

Symptoms. — Neuromata  often  cause  no  symptoms.  Perhaps 
the  most  frequent  evidence  of  their  presence,  however,  is  pain 
and  some  tenderness.  The  pain  is  exacerbating,  and  may  be 
stopped  sometimes  by  pressure  on  the  nerve  above  the  tumor. 
Paraesthesia,  anfesthesia,  paralysis,  and  reflex  spasm  may  be  pres- 
ent. Some  forms  of  intractable  headache  are  possibly  due  to 
multiple  neuromata.  Multiple  and  plexiform  neuromata  cause 
symptoms  less  often  than  a  single  larger  neuroma.  A  neuroma 
on  the  pneumogastric  or  other  splanchnic  nerve  may  cause  severe 
symptoms.  Multiple  (true)  neuromata  may  last  for  years  and 
cause  no  serious  inconvenience.  Malignant  neuromata  cause  al- 
ways such  symptoms  as  would  naturally  follow  irritation  and 
compression  of  a  nerve. 

The  diagnosis  of  neuroma  can  only  be  certainly  made  when 
the  tumor  can  be  felt.  In  other  cases,  by  exclusion  a  fairly  cer- 
tain conclusion  may  be  reached. 


DISEASES   OF  THE   PERIPHERAL  NERVES.  91 

True  neuromata  are  often  multiple ;  the  false  rarely.  Idiocy, 
heredity,  neuropathic  constitution,  scrofula,  would  all  favor  the 
view  of  the  disease  being  a  true  neuroma. 

The  treatment  is  essentially  surgical.  Internal  medication  and 
external  applications  are  of  little  value.  Strong  galvanic  cur- 
rents, mercury,  and  the  iodides  in  large  doses  may  be  tried  in  true 
neuromata  and  fibro-neuromata. 

Both  true  and  false  neuromata  may  return  after  extirpation. 


CHAPTER    TIL 

DISEASES   OF   THE   SPECIAL  NERVES. 

The  peripheral  nerves  are  the  cranial,  the  spinal,  and  the  off- 
shoots of  the  cranial  and  spinal,  known  as  the  sympathetic.  I 
shall  take  u})  first  the  cranial  nerves. 

The  Craxial  ^s^eryes. 

These  consist  of  twelve  pair,  viz. : 

1.  The  olfactory.  II.  The  optic.  III.  The  motor  oculi.  IV. 
The  patheticiis  or  trochlear.  V.  The  trigeminus.  VI.  he  ab- 
ducens.  VII.  The  facial.  VIII.  The  auditory.  IX.  The  glosso- 
pharyngeal and  nerve  of  Wrisberg.  X.  The  vagus.  XI.  The  ac- 
cessory vagus  or  spinal  accessory.     XII.  The  hypoglossal. 

The  first  two  are  not  strictly  nerves,  but  rather  parts  of  the 
brain. 

The  remainder  are  analogous  to  spinal  nerves,  and  arise  from 
the  mid  and  hind  brain. 

AxATOMY  AXD  PHYSIOLOGY.— I.  The  olfactoi^ynerve  consists: 
1.  Of  [peripheral  fibres  which  are  distributed  to  the  superior  and 
middle  turbinated  bones  and  upper  part  of  the  septum.  They 
are  connected  with  olfactory  cells  lying  in  and  beneath  the  mu- 
cous membrane.  They  are  about  twenty  in  number  on  each  side. 
They  are  non-medullated.  They  pass  up  through  the  cribriform 
IDlate  of  the  ethmoid  bone  and  enter  the  olfactory  bulb  (Fig.  48). 

2.  The  olfactory  bulb  is  in  man  a  rudimentary  organ  containing 
a  few  nerve  cells,peculiarbodies,perhapsofneurogha  tissue,  called 
glomeruli,  connective  tissue,  and  nerve  fibres.  It  is  analogous  to 
a  spinal  ganglion  or  to  a  nucleus  of  origin  of  a  nerve  in  the  cord 
or  medulla. 

3.  The  olfactory  tract,  wrongly  called  a  nerve,  is  composed  of 
cortical  nerve  cells  and  of  nerve  fibres.  It  has  three  roots,  the 
lateral,  middle,  and  mesial.  In  man,  only  the  lateral  is  of  im- 
portance. This  passes  along  the  margin  of  the  anterior  perforated 
space  to  the  uncinate  gyrus,  hippocampus,  and  cornu  ammonis. 
Some  fibres  also  pass  inward  into  the  anterior  commissure,  connect- 
ing the  tract  and  cortex  of  the  opposite  side  (Fig.  -18).    -i.  The  fourth 


DISEASES   OF   THE   SPECIAL   NERVES. 


93 


portion  of  the  olfactory  apparatus  is  the  uncinate  gyrus,  hippo- 
camiDus,  and  cornu  ammonis,  and  this  part  is  the  cortical  seat  of 
smell.  Further  connections  by  the  fimbria,  fornix,  corpora  mam- 
millaria,  and  optic  thalami  are 
thought  to  exist  (Hill) ;  also  direct 
connections  with  the  basal  gan- 
glia. The  olfactory  fibres  do  not 
decussate  like  the  other  nerves. 


Fig.  48. 


Fig 


Fig.  48.— Diagram  of  Olfactory  Nerves  and  Connections. 

Fig.  49,— The  Optic  Nervb  and  its  Central  Connections  (modified  from 
Obersteiner).  R,  Ketina,  darkonthesideconnected  with  left  hemisphere;  Ko,  optic 
nerve;  C/i,  chiasm;  Tro,  optic  tract;  CM,  Meynert's commissure;  CG,Guddeii's com- 
missure; r/to,  thalmus;  Cgl,  corpus  genie,  ext.;  Qa,  corpor.  quad.;  Ss,  optic  radia- 
tions; Co,  occipital  cortex;  iwi,  mesial  lemniscus.  (The  shading  of  the  retina  and 
visual  field  should  just  reach  the  vertical  lines.) 

The  sense  of  smell  is  rudimentary  in  man,  yet  it  is  still  the 
sense  by  which  we  can  appreciate  the  most  attenuated  matter ; 
for  the  trillionth  of  a  grain  of  mercaptan,  which  awakens  a 
sensation  in  the  mind,  has  weight  and  dimensions  so  infinitely 
minute  as  to  be  quite  beyond  the  power  of  the  imagination  to 
grasp.  According  to  Valentin,  we  can  perceive  rsohw^i  of  a  grain 
of  oil  of  roses.  According  to  Fischer  and  Penzoldt,  one  can  per- 
ceive ^TeooV^^Tnr  of  a  grain  of  mercaptan.  I  have  found  that  one 
can  perceive  the  odor  from  4  cm.  of  a  solution  of  oil  of  cloves  1 


94  DISEASES   OF  THE   NERVOUS   SYSTEM. 

to  100,000.  Matter  to  be  perceived  as  odor  must  be  in  a  gaseous 
form.  Odorous  sensations  co-operating  with  taste  sensations  form 
"  flavor."  Variety  in  odorous  sensations  depends  probably  upon 
the  rapidity  of  molecular  vibrations  as  in  the  case  of  light ;  and 
substances  having  similar  relations  in  vibration  have  similarity 
in  odor  (Haycraft).  Males  have  a  more  delicate  sense  of  smell 
than  females  (Xicolls  and  Bailey).  The  keenness  of  the  olfactory 
sense  is  lessened  in  the  insane  and  criminal  classes. 

II.  The  optic  nerve,  so  called,  is  really  a  central  tract  of  the 
brain,  like  the  olfactory  nerve. 

Traced  from  without  inward,  we  find  the  following  parts : 

1.  The  rods  and  cones,  with  the  filaments  connecting  them  to 
the  ganglionic  cells  of  the  retina,  really  form  all  that  there  is  of 
a  peripheral  optic  nerve.  These  rods  and  cones  number  about 
3,3G0,000. 

2.  From  the  ganglionic  cells  of  the  retina,  fibres  collect  and 
pass  into  the  cranial  cavity  as  the  optic  nerve.  This  nerve  con- 
tains about  438,000  fibres.  They  are  smaller  than  other  nerve 
fibres,  and  are  distinguished  from  them  by  having  a  neuroglia 
imbedding  substance  and  by  having  no  neurilemma. 

3.  The  optic  nerves  pass  to  the  optic  chiasm,  where  about  one- 
third  of  the  fibres  cross,  in  man.  In  lower  animals  the  decussa- 
tion is  greater.  After  leaving  the  chiasm,  the  fibres  form  the  optic 
tract.  This  tract  curves  up  and  back  around  the  crus  cerebri, 
and  divides  into  a  lateral  and  mesial  root. 

4.  These  roots  connect  with  the  external  geniculate  body,  the 
anterior  tubercles  of  the  corpora  quadrigemina,  and  the  posterior 
ganglion  of  the  thalamus  or  the  jDulvinar.  These  ganglia  are  called 
the  primary  optic  centres.  Through  the  anterior  tubercles  of  the 
corpora  quadrigemina,  and  by  other  means,  the  optic  nerve  is  con- 
nected with  the  oeuiomotor  nerve,  and  thus  reflex  movements  of 
the  pupils,  lids,  and  eyeballs  are  brought  about  (Fig.  49). 

5.  From  these  primary  optic  centres,  fibres  enter  the  posterior 
part  of  the  internal  capsule,  curve  up  and  back  toward  the  occip- 
ital lobes,  forming  the  optic  radiations  of  Gratiolet  {8s). 

6.  They  are  finally  distributed  to  the  cortex  of  the  occipital 
lobe,  and  in  man  chiefly  to  the  cuneus  and  the  upper  end  of  the 
first  occipital  gyrus. 

It  will  be  seen  that  each  retina  is  connected  with  the  occipital 
lobe  of  both  hemispheres.  It  is  further  known  that  the  outer 
or  temporal  half  of  each  retina  is  connected  with  the  occipital 
lobe  of  the  opposite  hemisphere,  and  the  inner  or  nasal  half  of 
each  retina  with  the  occipital  lobe  of  the  same  side.  Further,  the 
upper  part  of  each  retina  is  connected  with  the  lower  half  of  the 
cuneus,  and  vice  versa  (Fig.  49). 

Other  connections  exist  by  which  the  optic  centres  on  the  two 


DISEASES   OF   THE   SPECIAL   NERVES. 


95 


sides  are  connected  with  each  other  and  with  other  cranial  nerves 
in  the  medulla. 

The  optic  nerve  is  a  nerve  of  special  sense  of  vision  and  has  no 
other  function  except  that  of  an  excito-reflex  character. 

III.,  IV.,  VI.  The  motor  nerves  of  the  eye  are: 

{a)  The  third  or  oculo-motorius,  supplying  the  internal  supe- 
rior and  inferior  recti,  inferior  obliquus,  the  levator  palpebr^e,  the 
ciliary  muscle,  and  constrictor  of  the  iris. 

(&)  The  fourth  or  trochlearis,  supplying  the  superior  oblique. 


OVIN 

Fig.  50.  Fig.  51 . 

Fig.  50.— Diagram  showing  the  Arrangement  of  the  Ncclei  op  the  I\Iotor 
Nerves  of  the  Eye,  and  the  Decussations  of  the  Fourth  and  Internal  Rec- 
tus Branch  of  the  Third  Nerve. 

Fig.  51.— Diagram  showing  the  Probable  Relations  of  the  Nuclei  op  the 
Sixth  and  op  the  Internal  Rectus  Branch  op  the  Third  to  the  Brain. 


(c)  The  sixth  or  abducens,  supplying  the  external  rectus. 

(cZ)  The  sympathetic,  consisting  of  fibres  from  the  upper  cer- 
vical nerves  to  the  dilators  of  the  iris,  to  its  blood-vessels,  and  to 
Miiller's  muscle. 

2.  Motor  fibres  from  the  nucleus  belonging  to  the  third  nerve 
and  running  out  with  the  fibres  of  the  seventh  (Mendel),  supplying 
the  orbicularis  palpebrarum. 

The  third  and  fourth  nerves  arise  from  a  series  of  nuclei  in  the 
floor  of  the  aqueduct  of  Sylvius.  They  leave  the  brain  at  the 
anterior  edge  of  the  pons.  They  run  in  the  cavernous  sinus  and 
enter  the  orbit  through  the  sphenoidal  fissure. 

The  sixth  nerve  arises  from  a  nucleus  in  the  floor  of  the  fourth 
ventricle.     It  emerges  at  the  posterior  edge  of  the  pons,  runs  in 


96  DISEASES   OF   THE   NERVOUS   SYSTEM. 

the  cavernous  sinus,  and  enters  the  orbit  through  the  anterior 
lacerated  foramen. 

The  nuclear  gray  matter  from  which  these  nerves  arise  is 
made  up  of  a  series  of  nests  of  cells,  and  each  pair  supplies  a  differ- 
ent set  of  muscles  of  the  eye,  as  shown  in  the  diagram. 

The  nucleus  of  the  sixth  lies  farther  back  in  the  floor  of  the 
medulla,  but  it  belongs  to  the  same  serial  deposit  of  gray  matter, 
and  represents  the  continuation  of  the  anterior  horn  of  the 
spinal  cord  (Fig.  51). 

The  motor  nerves  of  the  eye,  third,  fourth,  and  sixth,  are 
closely  connected  with  each  other  and  other  nerves  by  a  long 
commissure,  the  posterior  longitudinal  bundle. 

The  fibres  of  the  third  and  fourth  nerves  pass  to  their  nuclei 
on  the  same  side,  then  decussate  and  pass  up  in  the  inner  part  of 
the  crusta  to  the  lower  i)art  of  the  central  convolutions  of  the 
cortex.  A  few  fibres  decussate  and  enter  the  nuclei  of  the  oppo- 
site side.     They  are  connected  with  the  internal  rectus  nucleus. 

The  fibres  of  the  fourth  nerve  almost  entirely  decussate,  run- 
ning forward  a  long  distance  before  they  finally  reach  their 
nuclei.  Thus  it  api3ears  that  the  abducens  is  the  only  cranial 
nerve  except  the  optic  which  largely  decussates  before  reaching 
its  nucleus.  However,  those  fibres  of  the  third  which  sui^ply 
the  internal  rectus  also  decussate,  as  already  stated. 

The  arrangement  of  the  nuclei  is  believed  to  be  about  as  fol- 
loAvs,  the  upper  on  the  list  being  anterior : 

Median  line, 
f  Sphincter  iridis,  Ciliarius. 
!  Levator  palp.,  Rect.  int. 
■  ^  '  j  Rectus  superior,  Rect.  inf. 
[^  Obliquus  inf. 

IV.   X.  -  Obliquus  superior. 
VI.  y.  -  External  rectus. 

In  order  to  understand  the  peculiarities  of  eye  palsies,  to  be 
described  later,  the  relations  of  the  sixth  to  that  nucleus  of  the 
third  nerve  which  innervates  the  internal  rectus  must  be  under- 
stood. In  turning  the  eyes  to  one  side,  these  two  nuclei  and 
their  nerves  act  together,  causing  the  external  rectus  of  one  eye 
and  the  internal  rectus  of  the  other  to  contract  at  the  same  time. 
The  impulse  from  the  brain  which  does  this  acts  first  upon  the 
sixth,  and  through  this  upon  the  -internal  rectus  nucleus  of  the 
same  side.  The  fibres  from  this  nucleus  cross  and  emerge  in  the 
third  nerve  fibres  of  the  opposite  side  to  the  sixth  nerve  nucleus. 
This  can  be  better  understood  by  the  diagram.  Fig.  51. 


1 


DISEASES   OF  THE   SPECIAL  NERVES. 


97 


Thus  lesions  in  the  brain  (at  a)  cause  paralysis  of  the  sixth 
nerve  of  the  opposite  side  and  internal  rectus  of  the  same  side. 
The  eyes  turn  toward  the  side  of  the  lesion. 

Lesions  in  the  pons  (at  b)  cause  paralysis  of  the  sixth  on  the 
same  side  and  internal  rectus  nucleus  of  the  opposite  side.  The 
eyes  turn  away  from  the  side  of  tlie  lesion. 

The  eye  muscles  move  the  eyeball  in  the  following  way; 

The  superior  rectus  elevates  the  eyeball. 

The  inferior  oblique  rotates  out  and  up. 

The  inferior  rectus  depresses  the  eyeball. 

The  superior  oblique  rotates  out  and  down. 


jV.  suprairoch. 
Ohl.  swper 


S.  supraorb. 

Rect.  sup, 
Levator,  p.- 


N-  infrafrroch. 

Pecf,  rved,     iU  #■* 


Red.  inf.  N.  supramax. 

Fig.  52.— The  Attachment  of  the  Eye  Muscles  to  the  Globe  (Merkel). 


The  superior  and  inferior  oblique,  acting  together,  rotate  in- 
ward. 

The  external  rectus  rotates  outw^ard. 

The  internal  rectus  rotates  inward. 

The  rectus  internus,  rectus  superior,  obhquus  inferior,  rotate 
upward  and  inward. 

The  rectus  internus,  rectus  inferior,  obliquus  superior,  rotate 
downward  and  inward. 

The  rectus  externus,  rectus  superior,  obliquus  inferior,  rotate 
out  and  up. 

The  rectus  externus,  rectus  inferior,  obliquus  superior,  out  and 
down. 

The  movements  of  the  eyeball  are  made  by  the  simultaneous 
action  of  several  muscles.  Most  of  them  act  as  their  names  indi- 
cate. But  the  oblique  muscles  help  to  depress  and  elevate,  and 
7 


98  DISEASES   OF  THE   NERVOUS   SYSTEM. 

then  help  to  rotate  in  or  out  according  as  the  internal  or  external 
rectus  is  acting 

The  cortical  centres  for  the  eye  muscles  are  not  positively 
known.  Lesions  in  the  inferior  parietal  lobule  sometimes  cause 
paralysis  of  the  third  nerve.  Lesions  of  the  posterior  part  of  the 
prefrontal  lobes  also  sometimes  cause  eye  palsies,  esi^ecially  con- 
jugate deviation. 

As  the  optic  nerve  is  the  special  sensory  nerve  of  the  eye,  so 
the  third,  fourth,  sixth,  and  part  of  the  seventh  nerves  are  the 
motor  nerves. 

By  means  of  the  optic  nerve  and  its  receptive  and  refractive 
apparatus,  the  form,  color,  movement,  and,  to  some  extent,  rela- 
tions and  distance  of  objects  are  determined.     The  motor  nerves 


I 


Dental 

Fig.  53.— The   Superiok   Maxillary   Division    op   the    Trigeminus   (Young- 
Baker). 

adjust  the  eye  to  near  and  distant  objects,  inform  us  as  to  size 
and  distance,  and  enable  us  to  follow  moving  objects  and  to  shift 
the  gaze  readily.  They  also  assist  in  protecting  the  eye  against 
injury. 

V.  The  trigeminus  or  fifth  nerve  is  one  of  the  most  extensively 
distributed  and  most  delicately  sensitive  nerves  of  the  body.  Its 
sensory  branches  represent  the  atrophied  and  lost  sensory  roots 
of  the  third,  fourth,  sixth,  seventh,  and  twelfth  cranial  nerves 
(Gaskill). 

It  has  a  most  extensive  primary  origin  by  three  principal  roots : 
(1)  The  ascending,  which  begins  in  the  upper  part  of  the  cervical 
cord  at  the  level  of  the  second  cervical  segment ;  (2)  the  descend- 
ing, which  rises  in  the  graj^  matter  about  the  aqueduct  of  Sylvius 
as  high  up  as  the  anterior  corpora  quadrigemina;  (3)  the  middle, 
which  arises  from  a  nucleus  in  the  pons  near  the  level  of  the 


DISEASES   OF   THE   SPECIAL   NERVES. 


99 


nerve's  exit.  The  ascending  root  is  mainly  sensory;  the  descend- 
ing, sensory  and  trophic ;  the  middle,  motor  and  sensory. 

The  gray  matter  from  which  the  trigeminus  arises  reaches  the 
whole  length  of  the  pons  and  medulla,  and  is  coextensive  with 
the  origin  of  all  the  other  cranial  nerves  (Fig.  57).  Hence  the 
frequency  with  which  its  disorders  are  complicated  with  those  of 
these  nerves.  Its  cortical  origin  is  jirobably  in  the  lower  part 
of  the  pre-  and  post-central  convolutions. 

The  trigeminus  supplies  sensation  to  the  face,  nose,  the  frontal 
and  maxillary  sinuses,  the  teeth,  the  palate,  tongue,  and  part  of 
the  upper  pharynx ;  also  to  the  scalp  as  far  back  as  the  vertex 

Gasserian  sauglion 


Foramen 
oval 


Fig.  54.— The  Inferior  Maxillary  Division  of  same  (Young). 


and  to  the  external  auditory  meatus.  It  giv^es  sensation  also  to  the 
anterior  three-fourths  of  the  dura  mater,  the  falx,  and  probably 
the  tentorium.  The  pia  and  arachnoid  are  not  sensitive.  The 
posterior  fossa  and  the  occipital  i)art  of  the  dura  mater  are  sup- 
plied by  the  vagus.  The  trigeminus  also  supplies  the  above-named 
parts  with  trophic,  vasomotor,  and  secretory  fibres.  The  vaso- 
motor fibres  are  brought  to  it  from  the  medulla  and  cervical  spinal 
cord  via  the  sympathetic ;  the  secretory  fibres  have  the  same  origin. 
Both  are  reinforced  by  the  four  ganglia  Avith  which  this  nerve  are 
in  close  connection.  An  exception  is  to  be  made  of  the  lachrymal 
fibres  which  are  brought  by  the  motor  nerves  of  the  eyeball. 

The  trigeminus  supplies  motion  to  the  muscles  of  mastication, 
viz.,  the  two  pterygoids,  the  temporal,  masseter,  mylo-hyoid,  and 
anterior  belly  of  the  digastric. 


100  DISEASES   OF  THE   NERVOUS   SYSTEM. 

VII.  The  facial  nerve  has  its  primary  origin  in  a  single  nucleus 
deeply  situated  in  the  lower  part  of  the  pons.  It  belongs  to  the 
same  series  of  nuclei  as  the  motor  nuclei  of  the  vagus,  glosso- 
pharyngeal, and  of  the  spinal  accessory;  in  other  words,  it  is  a 
l^rolongation  of  the  lateral  horn  of  the  spinal  cord.  It  has  not 
a  nucleus  common  to  it  with  the  sixth,  as  is  usually  stated. 
Those  fibres  of  the  nerve  which  go  to  the  orbicularis,  however, 
appear  to  come  from  a  nucleus  in  the  third  nerve  series  and  to 
reach  the  knee  of  the  facial  by  the  posterior  longitudinal  bundle 
(Mendel).  Tlie  deei?  fibres  of  the  facial  take  a  tortuous  course, 
l^assing  inward,  dorsally,  then  curving  down  and  out  around  the 
nucleus  of  the  sixth  nerve. 

The  cortical  origin  of  the  seventh  is  in  the  lower  part  of  the 
central  convolutions,  especially  the  precentral.  The  fibres  pass 
down  in  the  crusta  at  the  inner  side  of  the  pyramidal  or  motor 
tract.  They  decussate  and  reach  the  nucleus.  The  nerve  has  its 
exit  at  the  posterior  edge  of  the  pons,  external  to  the  sixth  nerve. 
It  then  has  to  take  a  long  course  through  a  bony  canal,  during 
Avhich  it  receives  taste  fibres  from  the  second  branch  of  the 
trigeminus  (or  the  glosso-pharyngeal).  These  fibres  leave  the  nerve 
as  the  chorda  tymi^ani,  and  join  the  lingual  branch  of  the  fifth 
nerve  to  supply  taste  to  the  anterior  two-thirds  of  the  tongue. 

The  facial  nerve  supplies'motion  to  all  the  muscles  of  the  face; 
to  the  stapedius,  stylo-hyoid,  buccinator,  and  platysma  myoid. 
It  also  contains  trophic  and  secretory  fibres.  It  does  not  supply, 
however,  the  muscles  of  mastication. 

The  taste  fibres  of  the  facial  nerve  apparently  come  in  many 
cases  from  the  second  branch  of  the  fifth  via  MeckeFs  ganglion, 
the  large  superior  petrosal  nerve,  and  geniculate  ganglion.  In 
other  cases  they  come  from  the  glosso-pharyngeal  nerve  via  the 
ganglion  petrosum,  Jacobson's  nerve,  tympanic  plexus,  and  genic- 
ulate ganglion.  Some  think  that  the  intermediary  nerve  of  Wris- 
berg,  which  arises  in  the  upper  joart  of  the  glosso-pharyngeal 
nucleus  and  connects  with  the  geniculate  ganglion,  carries  taste 
fibres  to  the  facial. 

YIII.  The  auditory  or  eighth  cranial  nerve  has  two  different 
parts.  One  portion  x^asses  to  the  cochlea  and  utricle  and  saccules ; 
it  has  to  do  Avith  the  sense  of  hearing ;  the  other  goes  to  the  semi- 
circular canals,  and  has  to  do  with  that  sense  by  which  Ave  ap- 
preciate position  of  our  body  and  its  relations  to  space.  The. 
eighth  nerve  is  thus  an  auditory  and  a  space-sense  nerve. 

The  auditory  fibres  enter  the  medulla  by  two  roots,  a  lateral 
or  posterior  and  a  median  or  anterior.  The  lateral  root  has 
mainly  auditory  fibres.  The  space-sense  fibres  enter  chiefly  by  the 
median  root.  These  roots  are  connected  with  three  nuclei,  viz.  ; 
(1)   The  chief  nucleus   (dorsal,  central,   inner  nucleus);    (2)  the 


DISEASES   OF   THE   SPECIAL  NERVES. 


101 


Carotid 


Spheno 
palatine  G. 


larg:e-celled  nucleus  (Deiter's) ;  and  (3)  the  accessory  nucleus  (ven- 
tral, anterior,  lateral).  The  chief  nucleus  (1)  is  a  large  mass  of 
gray  matter  composed  of  small  nerve  cells  and  lies  superficially 
just  beneath  the  floor  of  the  fourth  ventricle.  The  large-celled 
nucleus  (2)  lies  to  the  outer  side  of  and  below  it.  The  accessory 
nucleus  (3)  lies  in  the  substance  of  the  lateral  root,  and  between  it 
and  the  median  root.  The  lateral  root  is  the  one  coming  chiefly 
from  the  cochlea,  and 
is,  as  stated,  mainly  a 
nerve  of  hearing.  It 
is  connected  most  ex- 
tensively with  the 
accessory  nucleus, 
but  also  with  the 
other  nuclei. 

Through  the  acces- 
sory nucleus,  it  con- 
nects bj^  a  few  fibres 
with     the     superior 
olives  mostly  of  the 
opposite  side;  thence  fibres  pass  up 
through  the  lateral  lemniscus,  to  the 
posterior   corpora    quadrigemina ; 
thence  to  the  cortex  of  the  first  and 
second  convolutions  of  the  tempero- 
sphenoidal  lobes.     Other  fibres  pass 
up  directly  through   the    lemniscus 
and  the  tegmental  or  sensory  tracts 
to  the  cortex  of  the  temporal  lobes. 
Connections  are  numerous,  also,  with 
other  cranial-nerve  nuclei.     The  lat- 
eral root  also  sends 
fibres    to    the    chief 
nucleus  and  (via  the 
stria?  acusticse)   into 
the  raphe, and  thence 
to  the  f ormatio  retic- 
ularis   and     sensory 

tract.  These  fibres  go  also  to  the  posterior  tubercles  of  the  cor- 
pora quadrigemina  and  thence  to  the  cortex  of  the  temporal  lobe. 
The  median  root  is  connected  chiefly  with  the  large-cell  nucleus 
(2),  but  also  with  the  chief  nucleus  (1).  From  these  nuclei  fibres 
pass  up  in  the  posterior  cerebellar  peduncle  through  the  direct 
sensory  tract  of  the  cerebellum  to  the  roof  nucleus  or  the  emboli- 
form  and  globose  nuclei. 

IX.  The  glosso-pharyngeal  nerve  arises  from  three  nuclei  in 


Glosso-Pharyngeal  Nerve  (Young). 


102  DISEASES   OF  THE   NERVOUS   SYSTEM. 

the  medulla:  (1)  The  sensory  or  perhaps  visceral  nerve  cells  an- 
alogous in  character  to  those  of  the  column  of  Clark  in  the  spinal 
cord.  (2)  A  true  sensory  nucleus  consisting  of  a  long,  thin  de- 
posit of  gray  matter  continued  from  the  posterior  horn  of  the 
spinal  cord,  and  associated  with  a  strand  of  nerve  fibres  called 
the  ascending  root  of  the  vagus  and  pharyngeal  nerves  or  respi- 
ratory bundle.  (3)  A  motor  nucleus  Avhich  is  called  the  nucleus 
ambiguus,  and  is  a  continuation  of  the  lateral  horn  of  the  spinal 
cord  (Hill,  Gaskill). 

The  nerve,  therefore,  has  inotor,  sensory,  and  j^robably  visceral 
fibres.  It  supplies  general  sensation  to  the  tympanum  and 
pharynx  (in  connection  with  the  vagus)  and  upper  part  of  the 
larynx;  special  sensation  of  taste  to  the  posterior  third  of  the 
tongue,  and  motion  to  the  pharyngeal  muscles  in  connection  with 
the  vagus. 

Its  cortical  re^jresentation  so  far  as  taste  is  concerned  is  in  the 
hippocampal  gyrus.  The  nerve  gives  very  sensitive  reflex  fibres 
to  the  pharynx  and  is  important  in  the  reflex  act  of  deglutition ; 
it  also  carries  sensations  of  nausea  from  pharyngeal  irritation. 

X.  The  vagus  nerve  arises  from  three  nuclei  in  a  way  entirely 
similar  to  that  of  the  glosso-pharyngeal. 

1.  The  sensory  and  visceral  nucleus. 

2.  The  motor  nucleus,  called  the  nucleus  ambiguus,  which  is 
a  prolongation  upward  of  the  lateral  horn,  and  is  common  to  it 
and  the  glosso-pharyngeal. 

3.  The  sensory  nucleus,  which  gives  off  the  fibres  of  the  as- 
cending root  of  the  glosso-pharyngeal. 

The  nerve  is  closely  connected  with  the  glosso-pharyngeal 
above  and  with  the  accessory  (eleventh)  nerve  below. 

The  accessory  portion  of  the  spinal  accessory  is  practically  a 
part  of  the  vagus,  and  both  in  mode  of  origin  and  function  re- 
sembles it  closely.  It  arises  from  a  nucleus  which  lies  in  the  floor 
of  the  fourth  ventricle,  and  is  continuous  brainward  with  that  of 
the  vagus.  It  consists  of  small  cells  giving  origin  to  fibres  tha.t 
are  small  in  size  and  have  sensory,  vasomotor,  visceral  motor, 
secretory,  trophic,  and  excito-reflex  functions. 

The  vagus  and  accessory  part  of  the  eleventh  together  have 
an  extraordinarily  wide  distribution  and  diversity  of  function. 

X.  First  they  contain  motor,  inhibitory,  and  vasomotor  fibres. 
These  fibres  go  to  the  pharynx,  larynx,  trachea,  and  bronchi ;  to 
the  oesophagus,  stomach,  small  intestines,  and  spleen. 

2.  Sensory  fibres,  which  go  to  the  occipital  and  transverse  sin- 
uses and  dura  mater  of  the  posterior  fossa,  to  the  external  audi- 
tory meatus  in  part,  to  the  pharynx,  larynx,  and  trachea,  and  to 
the  oesophagus. 

3.  Excito-refiex    fibres,  which    go    to  the    lungs    and    heart, 


DISEASES   OP   THE   SPECIAL   NERVES. 


103 


stomach,  and  to  other  or<^ans  mentioned  as  supplied  by  the  vagus 
with  sensation. 

These  reflex  fibres  stimulate  or  inhibit  the  vasomotor  centre, 
the  respiratory  rhythm, 
and  the  cardiac  rhythm. 
They  also  excite  reflexly 
deglutition  and  respira- 
tory movements. 

The  secretory  fibres  go 
to  the  respiratory  tract, 
a3Sophagus,  stomach,  and 
pancreas  and  small  intes- 
tines. 

C  a  r  d  i  o  -in  h  i  b  i  t  o  r  y 
fibres  go  to  the  heart, 
while  reflex  accelerating 
fibres  and  inhibiting 
fibres  go  to  the  lungs. 
The  accessory  nucleus 
supplies  the  laryngeal 
adductors  and  the  cardio- 
inhibitory  fibres. 

XI.  The  spinal  jmrt 
of  the  spinal  accessori/ 
arises  from  the  lateral 
horn  and  outer  part  of 
the  anterior  horn  of  the 
spinal  cord.  Its  fibres  of 
origin  extend  down  as 
far  as  the  fourth  or  fifth 
cervical  roots.  The  fibres 
unite  in  the  cranium  and 
pass  out  through  the  pos- 
terior lacerated  foramen 
in  the  same  sheath  as  the 
vagus.  After  their  exit 
from  the  skull,  they  di- 
vide into  an  internal  and 
external  part.  It  is  the 
external  branch  which 
contains  the  fibres  of 
spinal  origin.  The  nerve 
receives  some  sensory 
fibres  from  the  first  and  sometimes  from  the  second  cervical  nerve. 
The  terminal  branches  receive  motor  fibres  from  several  cervical 
nerves.  The  spinal  accessory  contains  large  and  small  or  visceral 
fibres.     The  spinal  part  contains  only  the  large  fibres. 


Fig.  56.— The  Vagus  and  Spinal  Accessory 
Nerve  (Young). 


104 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


The  spinal  accessory  supplies  the  sterno-cleido-mastoid  almost 
exclusively,  but  only  the  upper  part  of  the  trapezius ;  the  rest  of 
this  muscle  is  supplied  by  the  cervical  and  dorsal  nerves.  The 
sterno-cleido-mastoid,  when  innervated,  draws  the  chin  up  and 
over  toward  the  opposite  side. 

The  upper  fibres  of  the  trapezius  draw  the  head  back  slightly 
and  down  toward  the  same  side. 

Physiologically  the  spinal  part  of  the  accessory  nerve  is  one 
of  the  motor  cervical  nerves ;  the  accessory  or  medullary  portion 
is  part  of  the  vagus,  and  has  visceral  and  sensory  as  well  as 
motor  functions.* 

XII.  The  hypoglossal  nerve  arises  from  a  long  and  large  nu- 
cleus lying  in  the  lower  part  of  the  floor  of  the  medulla  near  the 


Fig.  5r. — Longitudinal  Section  showing  the  Relative  Position  of  the  Cra- 
nial Nerve  Nuclei  (Edinger). 


median  line  and  to  the  outer  and  ventral  side  of  the  central  canal. 
The  nucleus  is  a  continuation  upward  of  the  anterior  horns  of 
the  spinal  cord  and  is  homologous  with  the  sixth,  fourth,  and 
third  nerve  nuclei  higher  ui3  (see  Fig.  57).  It  reaches  below  as 
far  as  the  decussation  of  the  pyramids  and  above  as  far  as  the 
glosso-pharyngeal  nucleus.  A  second  small-celled  nucleus  lies 
just  beneath  the  nucleus  proper.  Its  cortical  representation 
is  in  the  lower  end  of  the  central  convolutions,  to  which  it  is 
connected  by  fibres  that  pass  into  the  raphe  and  thence  to  the 
anterior  pyramids.  Its  fibres  pass  out  between  the  olivary  body 
and  the  anterior  pyramid.  At  its  origin  it  is  a  purely  motor 
nerve ;  it  receives  a  few  sensory  fibres  from  the  cervical  nerves  and 
the  vagus.     It  supplies  the  following  muscles : 

*  Dees  thinks  that  the  spinal  origin  of  the  Eleventh  is  continuous  above  with  the 
twelfth,  not  with  the  anterior  nucleus  of  the  tenth  He  denies  that  the  medullary- 
nucleus  sends  fibres  to  the  larjnix. 

The  internal  branch  of  the  eleventh  sends  motor  fibres  to  the  rectus  posticus 
(E.  Remak). 


DISEASES   OF   THE   SPECIAL  NERVES. 


105 


Intrinsic  muscles  of  the  tongue :  superior  and  inferior  longi- 
tudinal and  transverse.  The  extrinsic  muscles  of  the  tongue; 
hyoglossus,   genio-hyoglossus,   and  styloglossus.       (The   palato- 


Funic,  restif. 


B, 


VII 


Fig.  58.— Diagrams  showing  tue  Position  of  the  Cranial  Nerve  Nuclei  and 
THE  Floor  of  the  Fourth  Ventricle  QIerkle). 


106  DISEASES  OF  THE  NERVOUS  SYSTEM. 

glossus  and  Unguals  are  supplied  by  the  fifth  and  seventh  cranial 
nerves  respectively.)  The  depressors  of  the  hyoid:  the  thyro- 
hyoid and,  with  the  cervical  nerves,  the  sterno-hyoid  and  sterno- 
thyroid. The  elevator  of  the  hyoid:  genio-hyoid.  It  is  also 
thought  to  send  fibres  to  the  oral  muscles  (Tooth). 

The  hypoglossal  nerve  is  concerned  in  the  movements  of  the 
tongue  and  in  fixing  or  depressing  the  hyoid  in  mastication  and 
deglutition.  When  diseased,  therefore,  speech  and  deglutition 
are  affected.  The  small  nucleus  of  the  nerve  is  thought  to  con- 
trol the  finer  lingual  movements  of  articulation. 


J 


CHAPTER   YIIL 

DISEASES   OF   THE   CRANIAL  XERVES. 
Diseases  of  the  Olfactory  Nerve. 

The  olfactory  nerve  is  affected  clinically  by  loss  of  function  or 
anosmia,  increased  sensitiveness  of  function  or  hyperosmia,  and 
perversions  of  function  or  jiarosmia. 

Anosmia  is  far  the  most  common  disorder  of  olfaction. 

Etiology. — Its  usual  cause  is  disease  of  the  mucous  membrane 
of  the  nose.  Injuries,  inflammations,  and  tumors  affecting  any 
part  of  the  course  of  the  nerve,  its  bulb  or  central  fibres,  may 
also  cause  it.  Unilateral  cortical  lesions  in  the  uncinate  gyrus 
may  lead  to  partial  loss  of  smell.  It  will  be  not  entire,  because 
each  nerve  receives  fibres  from  both  hemispheres.  Paralysis  of 
the  fifth  or  seventh  nerve  may  indirectly  cause  some  anosmia. 
Primary  degenerative  changes  and  excessive  olfactory  stimula- 
tion cause  anosmia.  There  may  also  be  a  congenital  absence  of 
the  nerves.  Anosmia  occurs  sometimes  as  a  pure  neurosis  in 
hysteria  or  in  neurasthenic  states. 

Diagnosis. — This  is  made  by  test  odors. 

To  test  the  sense  of  smell,  a  bottle  of  oil  of  cloves  or  of  some 
familiar  non-irritating  odor  may  be  used.  To  detect  quantitative 
disturbance  one  may  use  six  phials  containing  oil  of  cloves,  in 
purity  and  in  watery  mixture  of  1  to  10,  1  to  100,  1  to  1,000,  1  to 
10,000,  and  1  to  100,000.  Special  olfactometers  have  been  devised. 
The  sense  of  smell  for  any  single  odor  is  lost  in  about  three 
minutes,  but  returns  after  one  minute's  rest. 

Treatment. — For  functional  anosmia,  snuffs  containing  str^'ch- 
nine  gr.  J^  and  gum  acacia  3  ij.  can  be  used.  Weak  galvanic 
and  farad ic  currents  are  recommended.  Usually  there  is  in  anos- 
mia a  local  catarrhal  condition  of  the  nose  which  requires  treat- 
ment. 

Hyperosmia  occurs  only  rarely  and  then  in  neurasthenic, 
hysterical,  or  insane  persons.  In  the  latter  it  is  more  often  a  psy- 
chical phenomenon  than  a  peripheral  disorder.  Hyperosmia  can 
be  cultivated,  and  this  is  done  sometimes  by  the  blind  and  by 
those  engaged  in  certain  pursuits,  such  as  tea-tasting  and  wine- 
tasting. 

Hallucinations  of  smell  occur  in  the  insane,  as  just  mentioned, 


108  DISEASES   OF   THE   NERVOUS   SYSTEM. 

and  a  few  cases  of  epilepsy  are  reported  in  which  the  cause  was  a 
stench.  When  all  olfactory  sensations  are  disagreeable  the  con- 
dition is  called  kakosniia. 

Parosmia  is  a  not  infrequent  condition.  In  it  everything 
smells  alike  to  the  patient,  and  the  odor  smelled  is  perhaps  a 
peculiar  or  offensive  one.  This  condition  may  be  due  to  local 
disease,  but  is  often  a  symptom  of  hysteria  or  neurasthenia. 

Diseases  of  the  Optic  Nerve  a^d  Centres. 

The  optic  nerve  may  be  affected  by  nearly  all  forms  of  patho- 
logical change.  For  the  neurologist,  however,  the  especially  im- 
portant conditions  are  inflammations,  degenerations,  injuries, 
and  functional  disorders. 

In  order  to  understand  the  descriptions  of  these  diseases,  it  is 
necessary  to  define  some  of  the  symptomatological  terms  used : 

Astheni02)ia  is  a  condition  in  which  exertion  of  the  eyes  is 
wearisome  and  painful. 

Amblyopia  is  a  partial  loss  or  dimness  of  vision  in  which  there 
are  no  observable  lesions. 

Amaurosis  is  a  total  blindnes.s  in  which  there  is  no  observable 
lesion. 

Hemianopsia  is  blindness  of  half  the  visual  field. 

Hemiopia  is  a  condition  in  which  there  Is  vision  in  one-half 
the  visual  field. 

Scotoma  is  a  name  given  to  blind  spots  or  areas  in  the  visual 
field. 

Inflammation  of  the  nerve,  or  optic  neuritis,  may  occur  as  a 
papillitis  or  inflannnation  of  the  head  of  the  nerve,  a  neuro-retini- 
tis  or  descending  neuritis,  a  perineuritis  or  a  retrobulbar  neuritis. 

Perineuritis  is  rare.  Neuro-retinitis  and  papillitis  are  closely 
associated  clinically  and  pathologically  (Noyes),  so  that  practi- 
cally only  two  forms  of  neuritis  need  be  discussed  separately. 

Papillitis  a^'d  Xeuro-retixitis.— £'f/o/o^?/.— The  causes 
in  general  are  tumor  and  inflammation  of  the  brain,  poisons, 
infections,  and  auto-toxtemic  states.  In  imrticular  the  causes 
are  tumors,  abscess  of  the  brain,  meningitis,  syphilis,  myelitis, 
nephritis,  diabetes,  infectious  fevers,  multiple  neuritis,  lead,  and 
severe  hemorrhages.  The  disease  occurs  at  all  ages  and  in  both 
sexes.  In  brain  tumors  it  occurs  in  two-thirds  of  the  cases,  and 
especially  often  in  cerebellar  tumors.  It  occurs  in  80  per  cent  of 
cases  of  tubercular  meningitis. 

Symptoms. — Subjective  symptoms  are  often  not  present.  The 
vision  may  remain  good  for  a  long  time.  In  other  cases  there  are 
concentric  limitation  of  the  visual  field,  loss  of  color  sense,  and 
scotomata.     For  a  description  of    ophthalmoscopic  changes,  the 


I 


DISEASES   OF  THE   CRANIAL  NERVES.  109 

reader  is  referred  to  special  text-books.  It  is  in  this  condition 
that  "choked  disc,"  which  is  a  papillitis  with  much  serous  infil- 
tration, occurs.  The  changes  are  less  striking  in  neuro-retinitis. 
The  disease  may  affect  one  or  both  nerves.  In  brain  disease 
both  nerves  are  usually  involved. 

Pathology  and  Pathological  Anatomy. — The  process  is  usually 
subacute  or  chronic.  Congestion,  exudation,  small  hemorrhages, 
and  collections  of  leucocytes  occur.  The  sheath  of  the  nerve 
just  back  of  the  globe  is  often  distended  with  a  serous  exudate. 
After  a  time  the  nerve  fibres  atrophy,  connective  tissue  prolifer- 
ates and  takes  their  place,  and  we  have  a  secondary  optic  atrophy. 


Fig.  59.— Neuro-retinitis  CJakger). 

The  process  is  essentially  peripheral,  but  it  extends  back  with 
lessening  intensity  into  the  trunk  of  the  nerve.  The  purely  me- 
chanical theory  of  neuritis,  that  it  is  due  to  compression,  cannot 
be  accepted  in  the  light  of  modern  pathology.  It  is  probable  that 
the  neuritis  results  from  an  irritating  serous  fluid  which  extends 
down  the  sheath  of  the  nerve,  this  sheath  being  a  prolongation 
of  the  arachnoid  cavity.  Mechanical  causes  lead  to  constriction, 
accumulation  of  the  fluid,  and  compression  of  the  nerve  at  its 
periphery,  and  hence  to  inflammation.  Sometimes,  at  least,  the 
irritating  fluid  contains  microbes  or  microbic  poisons. 

Retrobulbar  Neuritis.— In  this  disease  the  lesion  lies  chiefly 
behind  the  globe.  Its  causes  are  especially  toxaemia  from  alcohol 
and  tobacco.  It  is  also  due  to  rheumatic  influences,  syphilis,  lead, 
and  diabetes. 


110  DISEASES   OF   THE   NERVOUS   SYSTEM. 

In  the  acute  cases  there  is  usually  rather  rapid  loss  of  sight, 
with  some  pain  and  tenderness.  The  ophthalmoscopic  changes 
are  relatively  slight.  In  chronic  cases,  which  are  usually  toxic 
in  origin  and  due  to  alcohol  or  tobacco,  oroftenest  to  both,  there 
are  color  scotomata  or  absolute  scotomata  and  amblyopia. 
There  is  no  pain.  The  condition  is  known  as  tobacco  or  alcoholic 
amblyopia. 

The  prognosis  of  neuritis  varies  Avith  the  cause.  If  this  is 
removable,  as  in  the  toxctmiie,  recovery  is  the  rule.  This  is  a 
proof  that  in  neuritis  the  connective  tissue  is  the  part  chiefly  in- 


FiG.  60.— Papillitis,  "Choked  Disc/''  in  a  Case  of  Cerebral  Tumor. 

volved,  for  a  destroyed  or  atrophied  optic  nerve  does  not  recover. 
In  many  cases,  however,  atrophy  follows  the  neuritis. 

The  treatment  is  based  on  the  cause.  In  acute  cases  one  may 
use  cups,  salicylates,  the  iodides,  and  mercury:  later,  the  iodides 
and  strychnia.     Perfect  rest  to  the  eyes  should  be  enjoined. 

Degexeratiox  of  the  Optic  Nerve,  or  Optic  Atrophy. 
— This  condition  may  be  primary  or  secondary.  Secondary  atro- 
phy is  usually  the  result  of  a  neuritis.  I  shall  describe  h.eve pri- 
mary optic  atrophy. 

Etiology. — It  occurs  oftener  in  men  than  women  (three  to  one). 
It  occurs  as  part  of  locomotor  ataiia  in  less  than  half  the  cases ; 
other  degenerative  diseases  of  the  cord,  like  multiple  sclerosis, 
may  accompany  it.  Next  to  the  spinal  cord,  it  occurs  oftenest 
with  degenerative  diseases  of  the  brain,  such  as  multiple  sclerosis 


DISEASES   OF   THE   CPwANIAL   NERVES.  Ill 

and  general  paresis.  Hemorrhages,  alcoholism,  and  lead  may  be 
causes.     It  may  occur  without  known  cause. 

The  symptoms  are  those  of  gradual  decrease  of  acuity  of  vision, 
concentric  limitation  of  the  visual  field,  loss  of  color  sense,  dilata- 
tion and  immobility  of  the  pupil.  The  sense  of  sight  may  remain 
good  for  a  long  time.  Ophthalmoscopically,  the  nerve  disc  is 
opaque,  grayish,  or  dirty  looking,  and  often  has  a  cup-shaped  or 
"  cupped-disc  "  appearance.  The  vessels  are  smaller  and  few  in 
number. 

The  pathology  and  pathological  anatomy  is  that  of  a  paren- 
chymatous degeneration  with  loss  of  nerve  fibres,  which  are  re- 
placed by  connective  tissue. 

llYie  prognosis  is  almost  uniformly  bad. 

The  treatment  is  that  usually  of  the  cerebral  or  spinal  disease. 
Mercury,  iodides,  strychnia,  phosphorus,  and  iron  are  given. 
Warm  baths  and  salicylate  of  soda  sometimes  have  a  temporarily 
good  effect.  Strychnia  in  i)hysiological  doses  gives,  however,  the 
best  symptomatic  results.  Electricity  is  not  of  any  use.  Stretch- 
ing the  nerve  does  no  good.  Eserine,  pilocarpine,  and  santonin  or 
nitrate  of  silver  may  be  tried. 

The  optic  nerves  and  their  primary  and  cortical  centres  are 
subjected  to  various  other  diseases.  So  far  as  these  are  organic, 
they  will  be  described  in  detail  under  the  head  of  brain  dis- 
eases. But  there  are  certain  symptoms  often  of  functional  origin 
which  are  best  described  here.  These  are:  (1)  Amblyopia  and 
amaurosis ;  (2)  retinal  hyperaesthesia  and  dyssesthesia ;  (3)  hemi- 
anopsia. 

Amblyopia  axd  Amaurosis.— ^t^'oZo^/i/.— The  causes  are  inju- 
ries and  shocks,  hysteria,  migraine,  concussion  of  the  brain,  light- 
ning stroke,  and  severe  hemorrhages.  There  are  also  certain 
toxic  causes,  chiefly  alcohol  and  tobacco,  quinine,  and  salicylic 
acid.  Other  causes  are  glycosuria,  uraemia,  and  reflex  irritations, 
especially  of  the  trigeminal  nerve.  Night-blindness  and  snow- 
blindness  are  forms  of  functional  amblyopia. 

The  symptoms  are  diminution  or  loss  of  vision,  usually  sudden, 
temporary,  and  involving  both  eyes.  Amblyopia  in  hysteria  is 
usually  greater  in  one  eye  and  associated  with  concentric  limita- 
tion of  the  visual  field  and  disturbance  of  color  sense. 

Underlying  functional  amblyopia  there  may  be  a  peripheral 
anaesthesia,  a  psychical  or  cortical  anaesthesia,  minute  hemor- 
rhages, causing  temporary  pressure,  vascular  spasm,  and  anemia. 

The  prognosis  is  usually  good. 

The  treatment  is  purely  a  causal  one.  In  most  cases  one  must 
examine  for  drug  poison,  uraemia,  diabetes,  migraine,  or  a  hemor- 
rhage. 

Retixal    or   ocular    hyperesthesia  is    a    condition    in 


112  DISEASES   OF  THE  NERVOUS   SYSTEM.    . 

which  the  eye  is  abnormally  sensitive  to  hght.  It  may  be  due  to 
exposure  to  extreme  hght  or  to  seclusion  in  a  dark  room.  The 
neurologist  sees  it  oftenest  as  a  symptom  of  hysteria  {vide  Hysteria) 
and  perhaps  in  hypnotic  states.  It  occurs  in  mydriasis  and  al- 
binism. It  is  not  to  be  confounded  with  photophobia  due  to 
irritation  of  the  conjunctiva. 

Nyctalopia,  or  the  sense  of  seeing  better  in  a  dim  hght,  is  a 
form  of  the  disease. 

Hemianopsia  or  half-sightedness  may  be  due  to  a  functional 
or  organic  disorder  of  the  nerve  or  its  centres.  It  is  a  symptom 
of  many  lesions  and  conditions  and  can  only  be  described  gen- 
erally here. 

Etiology. — Its  principal  functional  causes  are  migraine,  lithae- 
mia,  gout.     Its  organic  causes  are  tumors,  inflammations,  soften- 


FiG.  61.— Showing  Lateral  Homonymocs  Hemianopsia.    This  is  not  quite  complete, 
there  being  a  space  on  the  blind  side  where  the  patient  can  see  (Noyes). 

ings,  or  hemorrhages  involving  part  of  the  optic  nerve  or  its  cen- 
tral connections. 

^ymj^toms. — Various  descriptive  terms  are  used  to  indicate  the 
character  of  the  hemianopsia.  In  lateral  hemianopsia  a  vertical 
half  of  the  field  is  involved.  In  lateral  homonymous  hemianopsia 
there  is  half -blindness  on  the  left  or  right  side  of  each  eye,  as  the 
case  may  be  (Fig.  61).  In  temi^oral  hemianopsia  the  outer  half 
of  each  eye,  and  in  nasal  the  inner  halves,  are  involved.  The 
upper  or  lower  segments  or  irregular  segments  of  the  visual  field 
may  be  involved. 

These  various  forms  of  hemianopsia  depend  upon  the  location 
of  the  lesion  which  cuts  into  and  destroys  the  optic  fibres  in  their 
course  from  the  eye  to  the  visual  centre  in  the  occipital  cortex. 
The  mechanism  will  be  understood  when  it  is  remembered  that 
each  occipital  lobe  is  supplied  by  nerve  fibres  from  one-half  of 
the  retina  of  each  eye.     A  cut  shows  this  better  than  any  descrip- 


I 


DISEASES   OF   THE   CRANIAL   NERVES.  113 

tion  (Fig.  49).  In  nasal  hemianopsia  the  lesion  must  be  at  Ch,  in 
front  of  the  chiasm.  In  temporal  hemianopsia  it  is  at  CM.,  just 
back  of  the  chiasm.  In  lateral  hemianopsia  the  lesion  must  lie 
farther  back  than  the  chiasm,  in  the  tract,  the  primary  centres, 
the  optic  radiations,  or  occipital  lobes. 

In  hemianopsia  from  disease  of  the  nerve  as  far  back  as  and  in- 
cluding the  primary  centres  in  the  optic  thalamus  and  corpora 
quadrigemina,  there  is  a  loss  of  light-reflex  when  a  ray  of  light 
is  thrown  upon  the  blind  side  of  the  retina,  but  the  pupil  still 
contracts  when  light  is  thrown  on  the  sensitive  side  of  the  retina. 
This  phenomenon  is  called  "  Wernicke's  hemiopic  pupillary  re- 
action." If  in  hemianopsia  the  light-reflex  is  preserved,  the  lesion 
is  back  of  the  primary  centres  and  involves  the  optic  radiations 
or  cortex. 

A  test  for  the  condition  of  hemianopsia  in  its  early  stage,  and 
one  that  is  useful  in  stupid  or  i:>artially  comatose  patients,  is  the 
following :  When  the  finger  is  suddenly  brought  in  front  of  the 
eye  on  the  sound  side,  there  is  a  wink ;  if  brought  in  front  from 
the  blind  side,  the  orbicularis  does  not  contract. 

Hemianopsia  is  almost  always  the  sign  of  organic  disease.  It 
is  not  found  in  hysteria,  but  does  occur  in  migraine  and  lithce- 
mia.  It  is  best  made  out  and  recorded  by  means  of  the  perimeter. 

Its  course  and  treatment  depend  ujoon  the  cause. 

Diseases  of  the  Motor  Nerves  of  the  Eye. 

The  common  affections  of  the  ocular  muscles  are : 

1.  Paralyses  or  ophthalmoplegias,  which  may  be  acute,  chronic, 
or  progressive.  2.  Pareses  or  amyosthenic  states,  called  ordina- 
rily muscular  asthenopias.  3.  Spasms,  such  as  strabismus,  nystag- 
mus, and  blephorospasm. 

There  are  many  special  terms  w^hich  are  used  to  indicate  the 
peculiar  effects  of  various  paralyses  and  spasms  of  the  ocular 
muscles  and  nerves,  and  some  of  these  I  will  define  here : 

Erroneous  projection  is  a  condition  in  which  the  patient  is 
unable  to  judge  exactly  of  the  relation  of  external  objects  to  the 
body.  For  this  relation  is  determined  by  the  movements  of  the 
ocular  muscles,  and  these  being  weak,  wrong  sensations  are  con- 
veyed to  the  brain.  Vertigo  may  result  from  this  disturbance  of 
muscular  sensation. 

Diplopia  or  double  vision  is  a  condition  due  to  the  erroneous 
sensation  resulting  from  eye-muscle  palsy,  and  to  the  fact  that  the 
images  of  the  object  fall  upon  non-corresponding  retinal  fields. 
Diplopia  is  simple  or  homonymous  when  the  false  image  is  seen 
on  the  same  side  as  the  affected  eye.  AVhen  a  red  glass  is  placed 
over  this  eye  two  images  are  seen,  the  red  one  being  on  the  side 
8 


114  DISEASES   OF  THE   NERVOUS   SYSTEM. 

of  the  eye  involved.  Diplopia  is  heteronymous  or  crossed  when 
the  false  image  is  on  the  opposite  side  to  the  sound  eye. 

Coiijugate  deviation  of  the  eyes  is  a  condition  in  which  both 
eyes  turn  strongly  to  one  or  the  other  side.  It  may  be  paralytic 
or  spasmodic.  The  mechanism  is  a  complicated  one  and  not 
Ijerfectly  understood.  In  general,  destructive  lesions  of  the  brain 
cause  a  paralytic  deviation  toward  the  side  of  the  lesion.  Similar 
lesions  in  the  pons  cause  a  deviation  away  from  the  side  of  the 
lesion.  The  palsy  involves  the  sixth  cranial  nerve  and  the  branch 
to  the  internal  rectus  from  the  third.  The  sixth  nerve  nucleus  is 
the  dominant  one,  and  impulses  from  the  brain  go  to  it  first  (see 
Fig.  51). 

Returning  now  to  the  diseases  of  the  motor  nerves  of  the  eye, 
it  is  found  that  the  paralyses  occur  in  various  ways,  which  may 
be  best  grouped  as  follows : 

Ophthalmoplegias : 

1.  Paralyses  of  the  third  nerve.  )  Acute. 

2.  Paralyses  of  the  fourth  and  sixth  nerves.  )  Chronic. 

3.  Progressive  paralysis  of  all  or  part  of  these  nerv^es. 

The  Ophthalmoplegias. 

I.  Paralysis  of  the  -Oculo-Motorius  or  Third  Nerte. 
— Etiology. — The  commonest  causes  are  exposure  to  cold  and 
syphilis.     Other  causes  are  basal  meningitis,  intracranial  tumors, 
injuries,  compression  from  orbital  tumors,  the  diphtheritic  poison, 
and  excessive  exposure  to  light ;   excessive 
use  of  tobacco,  and  alcohol,  morphine,  or 
other  poisons  may  be  a  cause.     Temporary 
palsy  sometimes  occurs  in  migraine,  or  it 
may  take  the  place  of  an  attack  of  migraine. 
A  palsy  of  some  of  the  muscles  supplied  by 
the  third  is  sometimes  caused  by  cerebral 
lesions    involving     the     inferior    parietal 
lobule.     Partial  palsies  also  occur  in  loco- 
motor ataxia  and  in  certain  primary  mus- 
cular atrophies.    The  common  causes,  how- 
FiG.  62.— Double  Ptosis,     ^"^'©r,  are,  as  stated,  rheumatic  influences 
and  syphilis. 
There  occurs,  in  rare  cases,  an  acute  inflammatory  degenera- 
tion of  the  nuclei  of  the  ocular  muscle  nerves  similar  to  acute  an- 
terior polio-myelitis.     This  condition  has  been  called  "  polio-en- 
cephalitis superior." 

Symj)toms. — When  all  the  muscles  supplied  by  the  third  nerve 
are  paralyzed,  there  is  dropping  of  the  lid  (ptosis) ;  the  eye  can 
only  be  moved  outward  and  downward  and  inward ;  there  is  there- 


DISEASES   OF  THE   CRANIAL  NERVES.  115 

fore  divergent  strabismus  and  double  vision  (diplopia).  The  pupil 
is  somewhat  dilated  and  does  not  contract  to  light,  owing  to  paral- 
ysis of  the  constrictors  of  the  iris ;  and  there  is  loss  of  power  of 
accommodation, so  that  the  patient  cannot  read  print  close  to  him. 
The  patient  suffers  under  annoyance  from  the  lid  drop  and 
the  double  vision,  and  there  is  sometimes  vertigo  and  jihoto- 
phobia.  Only  one  nerve  is  involved  at  a  time  as  a  rule.  The 
various  eye  muscles  supplied  by  the  third  are  rarely  all  attacked. 


Fig.  63.— Shutter  for  Testing  Pupil-reflex.  The  apparatus  admits  of  usingr 
colored  glasses  for  testing  hysteria  and  maUngering;  also  of  the  use  of  a  Maddox 
prism  for  testing  the  eye  muscles. 

The  levator  may  escape  almost  entirely  the  ciliary  muscle  and 
iris  may  also  be  but  slightly  involved ;  but  these  latter  muscles 
are  never  involved  alone  in  ordinary  types  of  the  disease. 

The  affection  usually  runs  a  subacute  course,  lasting  but  a  few 
weeks.  Functional  palsies  last  but  a  few  days;  syphilitic  palsies 
are  usually  temporary  (one  to  three  weeks),  but  may  relapse  or 
become  extremely  obstinate.  Periodical  palsies  occur  every  year 
or  six  months  or  even  oftener;  they  last  a  few  days  or  weeks  and 
are  accompanied  at  first  with  some  pain.  They  continue  to  recur 
for  years. 


116  DISEASES   OF  THE   NERVOUS   SYSTEM. 

In  diphtheritic  eye  palsies  the  first  three  or  four  nuclei  of  the 
series  making  up  the  origin  of  the  third  nerve  are  oftenest  af- 
fected, causing  paralysis  of  accommodation,  paralysis  of  the  iris 
and  of  the  internal  rectus,  the  three  muscles  concerned  in  accom- 
modating the  eye  to  near  objects  (Fig.  62). 

Pathology. — In  the  rheumatic  palsies  there  is  a  low  grade  of 
peripheral  neuritis,  and  the  same  is  true  of  most  diphtheritic  and 
other  palsies  of  infectious  origin.  In  syphilitic  palsies  there  is 
usually  a  specific  basilar  meningitis  involving  the  nerve  roots. 
The  meningitis  may  be  slight  or  may  amount  to  gummatous  de- 
posit. In  functional  and  some  i^eriodical  palsies  there  is  a  vaso- 
motor disturbance  causing  congestion  or  anaemia  or  perhaps  sim- 
ply inhibition  of  the  nuclear  centres.  Some  periodical  jpalsies 
have  been  found  to  be  due  to  small  tumors  involving  the  nerve 
root.  In  rare  cases  there  is  primary  muscular  atrophy  of  the  eye- 
ball nerves,  or  primary  degeneration  of  the  nuclear  centres,  or  a 
cerebral  lesion  of  the  inferior  parietal  lobule.* 

Diagnosis. — One  must  first  determine  how  extensively  the 
muscles  supplied  by  the  third  are  involved. 

If  only  the  levator  palpebrte,  there  is  simply  falling  of  the 
lid.  If  the  eyeball  muscles  are  involved,  we  get  the  following 
symptoms.     They  are : 

Limitation  of  movement  of  the  globe. 

Strabismus  and  secondary  deviation. 

Erroneous  projection. 

Double  vision  or  dij^lopia,  which  is  either  simple  or  crossed. 

Paralysis  of  the  iris  or  iridoiDlegia  and  of  the  ciliary  muscle 
or  cycloplegia. 

Concentric  limitation  of  the  visual  field. 

All  these  points  must  be  tested,  but  the  detailed  knowledge  of 
them  is  best  gained  by  consulting  ophthalmological  works. 

The  extent  of  involvement  of  eye  muscles  can  generally  be 
sufficiently  tested  by  making  the  patient  move  the  affected  eye  in 
various  directions,  and  by  testing  for  accommodation  and  for  the 
pupillary  reaction  to  light. 

Paralysis  of  the  iris,  or  iridoplegia,  and  of  the  ciliary 
muscle — cycloplegia. 

The  motor  fibres  of  the  third  nerve  to  the  iris  supply  the 
sphincter,  and  when  paralyzed  there  is  dilatation  and  immobility 
of  the  pupil,  a  condition  known  as  mydriasis. 

Fibres  from  the  same  nucleus  innervate  the  ciliary  muscle,  and 
the  iris  and  this  muscle  are  usually  paralyzed  together.  Paraly- 
sis of  the  ciliary  muscle  is  called  cycloplegia.  In  this  latter  con- 
dition there  is  loss  of  power  of  accommodation.     Iridoplegia  and 

*  Some  diphtheritic  palsies  are  probably  nuclear. 


DISEASES   OF   THE   CRANIAL   NERVES.  117 

cycloplegia  are  usually  due  to  local  disease  of  the  eye  or  to  the  use 
of  mydriatic  drugs.  Occasionally  they  are  observed  after  diph. 
theria  or  in  multiijle  sclerosis. 

Paralysis  of  the  levator  j^alpehrce,  csiusing  ptosis,  is  sometimes 
seen  alone,  but  usually  other  branches  of  the  third  nerve  are  in- 
volved. 

A  functional  palsy  of  the  lids  sometimes  occurs  in  anemic  and 
nervous  people  at  the  time  of  wakmg.  It  is  a  temporary  mo  ru- 
ing or  toaking  jJtosis. 

Paralysis  of  the  sympathetic  fibres  of  the  eye  causes  con- 
traction of  the  pupil  (myosis)  from  the  unopi)osed  action  of  the 
third  nerve.  There  is  also  a  slight  prominence  of  the  eye  and  slight 
ptosis  from  an  involvement  of  the  nerves  that  supply  MuUer's 
muscle.  The  pupil  does  not  dilate  when  the  skin  of  the  cheek  or 
neck  is  irritated.  This  is  a  condition  known  as  loss  of  skin-reflex. 
In  locomotor  ataxia  there  is  often  a  rigidity  of  the  constricting 
fibres  of  the  iris,  while  the  ciliary  muscle  continues  to  act.  The 
IDUpil  is  then  small  and  does  not  respond  to  light,  while  it  does 
respond  to  accommodation.  This  is  known  as  the  Argyll-liohert- 
son  pupil. 

II.  Paralysis  of  the  Fourth  ]S^erve.— This  is  a  rare  affec- 
tion and  not  always  easily  detected.  The  causes  are  much  the 
same  as  those  of  palsy  of  the  third  nerve. 

The  symptoms  are  slight  convergent  strabismus  when  the  ej^e 
is  moved  downward  and  diplopia  on  looking  down.  There  is 
defect  in  the  movements  of  the  eye  downward  and  outward. 

Paralysis  of  the  sixth  nerve  (abducens)  is  the  most  fre- 
quent of  eye  palsies,  and  occurs  especially  often  in  syphilis  and  in 
locomotor  ataxia.  It  causes  convergent  strabismus  and  double 
vision. 

III.  Progressive  Ophthalmoplegia. — Besides  the  palsies 
already  described,  there  occur  certain  forms  which  have  a  pecul- 
iar origin  and  course.  They  begin  sloAvly,  as  a  rule,  and  steadily 
progress.  In  some  cases  only  do  they  reach  a  certain  stage  and 
then  remain  chronic.  The  term  "  progressive  "  applies  fairly  well 
to  them.  They  often  affect  the  third,  fourth,  and  sixth  nerves 
together.  In  accordance  with  the  muscles  invaded,  these  palsies 
are  called  external,  internal,  j^artial,  and  total.  Thus  if  those 
branches  of  the  third  nerve  supplying  the  iris  and  ciliary  muscle 
are  involved  alone,  it  is  ophthalmoplegia  interna;  if  the  other 
branches  are  involved,  it  is  called  ophthalmoplegia  externa. 

Definition.— VYOgre^fiixe  ophthalmoplegia  is  a  degenerative 
disease  of  the  nuclei  of  the  motor  nerves  of  the  eye.  It  is  in  most 
cases  the  same  disorder  as  of  bulbar  paralysis  and  progressive 
muscular  atrophy.  It  is  sometimes  called  polio-encephalitis  su- 
perior. 


118  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Etiology. — It  develops  between  the  ages  of  fifteen  and  forty, 
but  may  occur  later.  The  sexes  are  equally  affected.  Lead,  diph- 
theria, traumatism,  syphilis,  appear  sometimes  to  be  the  cause. 
It  may  complicate  locouiotor  ataxia ;  more  often  it  forms  part  of 
I^rogressiv^e  muscular  atrophy. 

The  symjJtoms  are  often  not  noticed  until  the  disease  is  far 
advanced.  The  vision  is  not  disordered,  and  there  is  only  a 
gradual  limitation  of  mobility  of  the  eyeball.  A  slight  drooping 
of  the  lids,  causing  a  sleepy  look,  or  a  slight  squint,  usually  diver- 
gent, is  noticed.  Then  upon  examination  it  is  found  that  the 
eye  cannot  follow  the  finger,  except  to  a  slight  extent.  The  iris 
reacts  to  accommodation  and  light  usually.  Double  vision  may 
be  present.  Usually  the  patient  accustoms  himself  to  monocular 
vision.  The  disease  lasts  a  long  time,  and  it  may  become  sta- 
tionary. If  complicated  with  progressive  muscular  atrophy, 
however,  the  course  is  relatively  rapid,  death  occurring  from  the 
latter  disease  in  two  or  three  years. 

Pathological  Anatomy. — In  all  progressive  cases  there  is  a  de- 
generative atrophy  of  the  nuclear  cells.  In  a  few  rare  cases  no 
lesion  has  been  found,  and  in  a  few  stationary  cases  the  anatom- 
ical change  is  that  of  neuritis. 

The  treatment  is  that  for  the  disease  which  it  complicates  or 
the  condition  which  causes' it.  That  is  to  say,  it  is  the  treatment 
for  locomotor  ataxia,  jDrogressive  muscular  atrophy,  syphilis,  or 
lead-poisoning.  Iodide  of  potassium,  strychnia,  arsenic,  nitrate 
of  silver,  and  phosphorus  may  be  given.  Electricity  is  of  very 
doubtful  value,  and  only  the  galvanic  current  would  be  indi- 
cated. General  tonic  measures  and  rest  to  the  eyes  should  be 
employed. 

Muscular  Asthexopia  axd  Muscula.r  Ixsufficiexcies. 
— This  is  a  term  employed  to  indicate  a  lack  of  equilibrium  of  the 
muscles  of  the  eye,  as  a  result  of  which  the  visual  axes  cannot  be 
kept  parallel  without  an  effort.  This  effort  is  often  unconscious, 
and  shows  itself  only  by  a  ready  tiring  of  the  eye  on  attempting 
to  read,  or  by  the  production  of  headaches  and  cerebral  partes- 
thesite. 

Examination  of  the  eye  by  means  of  prisms  reveals  the  spe- 
cial character  of  the  trouble. 

When  the  eye  muscles  act  normally  the  condition  is  called 
one  of  orthophoria. 

When  some  of  the  muscles  are  weak  it  is  called  heterophoria. 
There  are  various  forms  of  heterophoria,  viz. :  esophoria,  a  tend- 
ing of  the  visual  lines  inward,  from  weakness  of  the  externi ;  ex- 
ophoria,  a  tending  of  visual  lines  outAvard ;  hyperphoria,  a  tend- 
ing of  visual  line  of  one  eye  above  its  fellow\ 

The  condition  is  tested  in  various  ways.     The  simplest  is  this : 


DISEASES   OF   THE   CRANIAL   NERVES.  119 

Refractive  errors  having  been  corrected,  a  series  of  prisms  is  placed 
over  the  eye  at  first  with  the  base  inward  while  the  patient 
looks  at  a  candle  twenty  feet  distant.  The  prisms  are  increased 
in  strength  until  ttie  patient  can  no  longer  coalesce  the  images. 
The  degree  of  prism  is  noted,  and  this  indicates  the  strength  of  ab- 
duction or  of  the  externi. 

The  same  process  is  gone  through  with  for  the  interni,  the  base 
of  the  prism  being  oat. 

The  externi  should  overcome  a  prism  of  about  8",  the  interni 
one  of  2?i  to  25  or  more.  There  are  great  individual  variations, 
and  there  is  also  considerable  variation  ni  individuals. 

The  above  tests  measure  the  amount  of  abduction  and  adduc- 
tion. 

To  test  the  presence  of  heterophoria,  the  writer  uses  the  Mad- 
dox  double  prism  held  in  a  frame.  The  line  where  the  bases  of 
the  two  prisms  unite  is  brought  directly  over  one  eye,  and  is  held 
there  in  a  perfectly  horizontal  position  while  the  patient  looks 
at  a  candle  twenty  feet  away.  A  red  glass  is  at  the  same  time 
held  over  the  other  eye.  With  the  eye  covered  by  the  double 
prism  the  patient  sees  double,  one  flame  being  above  the  other, 
with  the  other  eye  he  sees  a  red  flame  lying  just  between  the  two 
white  ones.  If  the  red  flame  is  directly  in  a  vertical  line,  there 
is  orthophoria ,  but  if  it  lies  to  one  side  or  the  other,  there  is  ex- 
ophoria  or  esophoria  according  as  the  red  flame  was  on  the  oppo- 
site side  to  the  eye  covered  with  red  glass  or  on  the  same  side. 
If  heterophoria  is  found,  prisms  are  placed  over  the  eye  until  the 
three  lights  are  in  a  vertical  line.  The  number  of  the  prism  re- 
quired to  correct  the  heterophoria  indicates  its  extent  in  degrees. 

By  changing  the  double  prism  so  that  its  common  base  line  is 
vertical,  the  test  for  hyperphoria  can  be  made.* 

Muscular  asthewypia  is  said  to  cause  a  disturbance  of  vision, 
vertigo,  migraine,  cerebral  par^esthesia,  and  pains  in  the  head, 
more  particularly  in  the  occipital  and  cervical  region.  It  is  be- 
lieved to  be  a  possible  factor  in  producing  choreic  twitchings 
in  the  face.  In  neurasthenic  persons  it  may  cause  a  wider  range 
of  nervous  symptoms.  It  is  said  to  be  an  essential  factor  in  caus- 
ing epilepsy,  chorea,  and  hysteria.  The  author  cannot  accept 
this  latter  view,  and  believes  that  the  importance  of  muscular 
asthenopia  in  causing  general  nervous  symptoms  is  not  great. 
Much  of  it,  if  not  all,  may  be  relieved  by  correcting  refractive 
errors  and  by  helping  the  general  health  of  the  patient. 

The  treatment  of  it,  after  all  myopia,  or  hypermetropia,  or 
astigmatism,  if  present,  is  relieved,  consists  in  the  systematic  use 
of  prisms  for  training  the  muscles,  the  wearing  of  proper  glasses, 

*More  elaborate  and  exact  methods  have  been  devised  by  Dr.  Stevens  and  are 
employed  by  many  ophthalmologists. 


120  DISEASES   OF  THE   NERVOUS   SYSTEM. 

and  graduated  or  complete  tenotomies  according  to  the  method 
of  Stevens. 

Spasmodic  Diseases  of  the  Ocular  Muscles. 

These  are-  (1)  Conjugate  deviation  from  spasm;  (2)  irregular 
and  associated  spasms  from  convulsive  and  irritative  brain  dis- 
order; (3)  nystagmus. 

Etiology. — iSpas?nodic  conjugate  deviation  occurs  from  an  irri- 
tating lesion  of  the  ocular  nuclei  or  of  the  brain  in  its  cortical 
motor  areas  and  tracts. 

Irregular  spasmodic  movements  occur  in  meningitis,  hydro- 
cephalus, and  in  lesions  involving  the  semi-circular  canals.  Pecul- 
iar associated  spasms  occur  in  hysterical  attacks. 

Various  spasmodic  movements  and  contractions  of  individual 
eye  muscles  occur  from  ocular  disease,  errors  of  refraction,  mus- 
cular weakness  and  paralysis  of  certain  eye  muscles. 

Rhythmical  spasm  or  nystagmus  occurs  as  the  result  of  hered- 
itary visual  Aveaknesses  and  refractive  errors  of  various  kinds,  in 
albinoes,  and  in  chronic  hydrocephalus.  It  is  found  usually  in 
neurotic  cases  associated  with  ocular  defects,  in  epilepsy,  chorea, 
hj'steria,  neurasthenia,  and  insanity.  It  occurs  in  certain  degen- 
erative nervous  disorders  such  as  disseminated  sclerosis,  heredi- 
tary ataxia,  tumors,  especially  of  the  cerebellum,  and  other  focal 
lesions,  and  in  meningitis.  It  occurs  in  miners,  and  is  called 
miners'  nystagmus.  It  may  be  a  reflex  symptom  from  a  remote 
irritation. 

In  nj'stagmus  the  oscillation  of  the  eyeballs  is  usually  lateral. 
It  may  be  brought  out  when  slight  in  degree  by  causing  the  pa- 
tient to  look  steadily  to  one  side. 

Vertical  and  a  kind  of  rotating  nystagmus  sometimes  occur, 
and  are  due  to  much  the  same  causes  as  those  of  lateral  nystag- 
mus. 

Spasj7i  of  the  levator  pal pehrce  is  sometimes  seen,  and  is  usually 
tonic. 

DISEASES   OF  THE   FIFTH   CRANIAL   NERVE— THE 
TRIGEMINUS. 

The  common  affections  of  this  nerve  are  headache,  migi*aine, 
tic  douloureux,  and  various  neuralgias.  The  rarer  diseases  are 
anaesthesia,  reflex  cough  and  asthma,  masticatory  paralysis,  tris- 
mus, trophic  and  secretory  and  vasomotor  disorders. 

Many  of  the  disorders  referred  to  the  fifth  nerve  are  in  reality 
only  symptoms  of  some  general  neurosis,  constitutional  disturb- 
ance, or  of  some  remote  local  disease.  As  a  matter  of  conven- 
ience, however,  they  may  be  treated  here. 


DISEASES   OF  THE  CRANIAL  NERVES. 


121 


Headache  (Cephalalgia). 

Headache  is  the  name  given  to  attacks  of  diffuse  pain  affecting 
different  parts  of  the  head  and  not  confined  to  the  tract  of  a 
particular  nerve.  It  usually  comes  on  in  paroxysms  at  various 
intervals,  but  may  be  continuous. 


Fig.  64.-SHOWING  the  Motor  anu  8i:nsokv  Nerves  and  the  Arteries  and 
Veins  of  the  Face  (Merkel).  a.  Frontal  nerve  :  b,  supra-orb.  ;  c.  temporal  .  a 
lacrvmal :  e.  supra-  aud  inf ra-trochlear :  /.  auriculo  temp. ;  g,  nasal ;  h,  malar :  t,  se^^'^a 
nerve;  k.  infra-orbital;  m,  mental.  The  veins  have  longitudinal,  the  arteries  oblique 
striations.    The  nerve  i  is  the  facial ;  all  the  other  branches  are  trigemmaL 


122  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Etiology. — Headache  is  the  most  common  of  nervous  symp- 
toms. Ten  to  fifteen  per  cent  of  school  children,  twenty-five  per 
cent  of  men,  and  over  fifty  per  cent  of  women  are  subject  to  it 
more  or  less. 

The  headache  ages  are  from  ten  to  twenty-five  and  thirty-five 
to  forty-five;  most  cases  occur  between  the  ages  of  eight  and 
twenty-five,  especially  in  females.  The  number  of  headaches  in- 
creases gradually  from  the  period  five  to  ten  years  up  to  the 
period  fifteen  to  twenty,  then  falls  till  the  thirty-fifth  year,  and 
rises  again  till  about  the  age  of  forty.  Early  childhood  and  de- 
clining age  are  practically  exempt  from  chronic  functional  head- 
aches. Women  suffer  from  it  more  than  men  in  the  proportion  of 
about  three  to  one.  It  is  more  frequent  in  city  populations  and 
among  the  wealthier  classes.  Headaches  are  more  common  in 
the  spring  and  fall  and  in  temperate  climates.  Headaches  may 
be  classed,  in  accordance  with  their  causes,  as  follows: 

1.  Hiemic  causes,  in  which  impoverished  or  disordered  blood 
is  brought  to  the  brain,  as  in  {a)  anemia  and  congestion;  {h) 
diathetic  states:  gout,  rheumatism,  diabetes,  ursemia;  (c)  infec- 
tions: malaria,  fevers. 

2.  Toxic  causes:  lead,  alcohol,  tobacco,  etc. 

3.  Neuropathic  states:  epilepsy,  neurasthenia,  hysteria,  neu- 
ritis. 

4.  Reflex  causes  ocular,  naso-pharyngeal,  auditory,  dyspeptic, 
sexual. 

5  Organic  disease,  including  arterio-sclerosis,  syphilis,  tumors, 
meningitis,  and  diseases  of  the  cranial  bones.  The  anaemic,  dys- 
peptic, ocular,  and  neurasthenic  are  the  common  forms  of  chronic 
and  recurrent  headache. 

Symptomatology . — Headaches  may  be  classed  in  accordance 
with  their  location  and  the  character  of  the  pain.  We  have  ac- 
cordingly; 1.  frontal  headaches;  2,  occipital  headaches,  3.  parie- 
tal and  temporal  headaches;  4,  vertical  headaches;  5,  diffuse 
headaches  and  various  combinations  of  the  above. 

The  most  common  form  of  headache  is  the  frontal,  next  the 
fronto-occipital  or  diffuse,  next  the  vertical,  and  then  the  occip- 
ital. 

The  kind  of  pain  differs  with  different  persons  and  with  differ- 
ent causes.  We  have:  1,  pulsating,  throbbing  headache,  2,  dull, 
heavy  headache ;  3,  constrictive,  squeezing,  pressing  headache ;  4, 
hot,  burning,  sore  sensations;  5,  sharp,  boring  pains. 

The  first  form  characterizes  headaches  with  vasomotor  dis- 
turbances, and  usually  indicates  migraine. 

The  second  is  of  a  toxic  or  dyspeptic  type. 

The  third  is  found  m  the  neurotic  and  neurasthenic. 

The  fourth  in  rheumatic  and  an;^emic  cases. 


DISEASES   OF   THE   CRANIAL    NERVES.  123 

The  fifth  in  hysterical,  neurotic,  and  epileptic  cases. 

The  accompanying  diagram  shows  some  of  the  relations  of 
localized  pain  to  the  cause.  A  large  experience  both  in  my  own 
practice  and  in  that  of  others  shows  it  to  be  approximately  cor- 
rect. 

Headaches  may  continue  for  a  day  or  may  last  for  weeks  and 
months.  Some  persons  have  headaches  only  when  constipated  or 
bilious,  or  when  they  have  an  attack  of  indigestion.  Others  suffer 
from  a  little  pain  nearly  all  the  time,  exacerbations  occurring  at 
various  periods.  Neurasthenic  and  ocular  headaches  are  gener- 
ally of  this  type.  When  headaches  are  persistent,  examination 
should  be  made  of  the  eyes,  of  the  nose  and  sinuses ;  the  patient 
should  be  questioned  as  to  syphilis,  the  continuous  use  of  tobacco, 
and  chronic  dyspepsia.    The  possibility  of  brain  tumor,  of  pachy- 


Anaemia. 

Endometritis. 

Bladder? 


Constipation. 
Caries  of  incisor. 


Error  of  eye-refraction, ,  ^     ^^  #  ,-    ^  ,  ^  '/■  vT'  /--^  Decayed  teeth. 
Gastric  dyspepsia  ;     --^^^H  i  ^=-::-f:\ -/rhinopharyngitis, 
cured  by  acids  ^-^^^  A    ]>;!.'"  Otitis  media. 

L^  A'W^    Uierine 

W  /       7  Spinal  irrita- 

>  y  I  tion 

Fig.  65.— Showing  the  Location  of  the  Pain  in  Headaches  from 
Different  Causes. 

meningitis  from  blows,  or  sunstroke  or  chronic  alcoholism  should 
be  considered. 

The  persistent  headaches  not  relieved  by  ordinary  treatment 
are  due  to  eye  trouble,  antemia,  neurasthenia  or  spinal  irritation, 
syphilis  or  pachy-meningitis.  Eye  strain  may  cause  true  migraine 
or  ordinary  headache.  Eye-strain  headache  is  usually  asociated 
with  some  weakness  of  eyesight  and  pains  and  discomfort  about 
the  globe,  besides  severer  pains  at  times  in  the  brow  or  occiput. 
The  cause  of  the  eye  strain  is  usually  astigmatism  and  hyperme- 
tropia.  Occasionally  it  is  due  to  weakness  or  lack  of  balance  of 
the  eye  muscles. 

^limptoms  Associated  loith  Headache.— The  symptoms  often- 
est  associated  with  chronic  and  recurrent  headaches  are  vertigo, 
somnolence,  sensations  of  heat  and  pressure  (cerebral  partesthe- 
sice),  and  nausea.  Vertigo  goes  oftenest  with  headaches  of  dys- 
peptic origin:  some  of  the  so-called  bilious  headaches  of  early 
life  develop  later  into  attacks  of  vertigo ;  this  symptom  often 
occurs  with  frontal  headaches.  Somnolence  occurs  oftenest  with 
amemic  and  malarial  headaches;  it  may  develop  also  with  syph- 


124  DISEASES   OF  THE   NERVOUS   SYSTEM. 

ilitic  head  iDains.  ;Xausea  I  have  found  oftenest  with  occipital 
headaches. 

Pathology. — Headaches  are  to  be  distinguished  from  neural- 
gias and  from  a  si^ecial  and  connnon  form  of  head  pain  known  as 
migraine. 

Headaches  are  diffused  pains  caused,  as  a  rule,  by  irritations 
located  in  or  referred  to  the  peripheral  ends  of  the  fifth  nerve. 
Their  seat  is  usually  within  the  skull. 

^^euralgias,  on  the  other  hand,  are  caused  by  irritations  of  the 
trunks  of  these  nerves.  The  jDains  are  local  and  confined  to  the 
single  branches  of  the  nerve. 

Migraine  is  a  periodical  neurosis  in  which  there  is  a  discharge 
of  nerve  force,  not  only  affecting  the  trigeminus,  but  often  other 
cranial  nerves  as  well  as  sympathetic  fibres. 

It  is  a  general  disease  of  which  the  headache  is  only  one  symp- 
tom. 

The  nerves  of  the  dura  mater  are  those  most  involved.  Head- 
aches, when  occipital,  involve  the  sensory  fibres  of  the  vagus  and 
the  upper  four  cervical  nerves. 

There  is  no  anatomical  change  in  the  nerves  except  in  organic 
headaches.  But  in  many  cases  the  tiiembranes  of  the  brain  and 
their  sensory  nerves  are  congested  or  anaemic. 

Diagnosis. — Xo  symptoiii  requires  more  careful  investigation 
as  to  its  cause  than  that  of  headache.  The  diagnosis  is  always  to 
be  made,  not  of  this  symptom,  but  of  its  cause.  Most  of  the  fore- 
going description  accordingly  refers  to  etiology. 

It  is  important,  however,  to  decide  whether  the  case  is  one  of 
migraine,  or  neuralgia,  or  of  headache. 

Headache  is  usually  diffuse  and  bilateral.  It  is  more  or  less 
persistent.  Migraine  comes  on  j)aroxysmally,  lasts  a  short  time, 
and  then  leaves  the  patient  feeling  perfectly  well  or  even  better 
than  ever.  Migraine  is  often  accompanied  with  nausea,  flashes 
of  light,  strong  pulsations  of  the  head,  vertigo,  pallor  or,  more 
rarely,  congestion  of  the  face.  Neuralgic  pains  are  sharp  and 
shooting,  they  run  along  the  tract  of  the  nerve,  and  often  are 
associated  with  suffusion  of  the  eye  and  oedema.  Tender  points 
are  felt. 

Treatment.— The  constitutional  treatment  is  based  upon  the 
etiology.  Regulation  of  diet  and  digestion,  securing  a  regular 
movement  of  the  l)owels,  attention  to  ocular  troubles,  abstention 
from  tobacco  and  alcohol  and  overwork  are  the  important  points 
requiring  attention. 

The  symptomatic  treatment  consists  in  giving  antipyrine,  anti- 
febrin,  phenacetin,  salicylate  of  soda,  caffeine,  muriate  of  annno- 
nia,  and  sometimes mori)hine  or  codeia,  and  l)romide  of  ammonia. 

Antipyrine  can  be  given  in  doses  of  gr.  v.  every  twenty  minutes 


I 


DISEASES   OF   THE   CRANIAL   NERVES.  125 

till  three  or  four  doses  are  taken.  Phenacetin  often  needs  to  be 
^iven  in  large  doses  of  ten  or  even  twenty  grains.  Antifebrin  is 
less  trustworthy  and  must  be  given  in  small  doses.  Exalgin  is 
not  a  very  good  or  safe  remedy.  It  may  be  tried  in  doses  of  gr. 
iij.  to  gr.  V.  Muriate  of  annnonia  is  an  excellent  remedy  given  in 
very  large  doses,  3  ss.  toji.,  well  diluted.  Menthol  in  doses  of 
gr.  V.  to  gr.  X.  in  hot  water  sometimes  stops  headaches.  In  head- 
aches from  anaemia,  cafieine  and  anmionium  muriate  are  best.  In 
headache  from  nervous  exhaustion,  similar  stimulating  anodynes 
are  usually  most  efficacious.  Combination?  of  caffein  citrate  and 
salicylate  of  soda  or  benzoateof  sodaare  of  ten  better  than  the  sin- 
gle drug.  Caffeine  in  any  case  nmst  be  given  in  larger  doses  than 
is  ordinarily  done,  i.e.,  gr.  iv.  or  v.  Local  applications  of  a 
twenty-percent  solution  of  menthol,  the  ice-bag,  cloths  wrung 
out  in  hot  water,  or  a  piece  of  sheet  lint  soaked  in  chloroform 
liniment  two  parts  and  tincture  of  aconite  one  part  are  efficacious 
measures.  A  cathartic,  rest  in  a  darkened  room,  light  diet — all 
these  are  measures  which  many  patients  themselves  learn  to 
adopt. 

Finally,  in  headaches  from  organic  disease  we  have  often  to 
resort  to  iodide  of  potassium,  mercury,  and  the  use  of  some  prep- 
aration of  opium. 

As  will  be  seen,  each  case  of  headache  requires  special  treat- 
ment and  a  certain  amount  of  experimentation  in  order  to  learn 
the  idiosyncrasy  of  the  patient. 

Migraine,  Sick-Headache,  Hemicrania.— Migraine  is  a 
constitutional  neurosis  characterized  by  periodical  attacks  of  pain 
chiefly  in  the  course  of  the  fifth  nerve.  The  pain  is  often  asso- 
ciated with  nausea  or  vomiting,  mental  depression,  vasomotor 
disturbances  such  as  flushing  or  pallor  of  the  face,  by  flashes  of 
light,  vertigo,  tinnitus  aurium,  and  in  rare  cases  by  partial  paral- 
ysis of  one  oculo-motor  nerve. 

It  will  thus  be  seen  that  migraine  is  more  than  ordinary  head- 
ache and  unlike  an  ordinary  neuralgia. 

Etiology.— The  disease  is  very  common  in  civilized  countries 
and  is  frequent  in  America.  It  oc<rurs  oftenest  in  women  in  the 
l)roportion  of  about  three  to  one,  and  it  begins  in  most  cases  at 
or  a  little  before  the  age  of  puberty.  It  may  begin  as  early  as 
the  fifth  or  even  the  second  year.  It  occurs  in  neurotic  families, 
and  there  is  very  often  a  history  of  direct  inheritance.  Other 
neuralgic  troubles,  epileijsy,  and  gout  may  be  found  in  the  family 
history. 

The  attacks  occur  oftenest  in  the  winter  in  our  climate. 

The  cases  that  begin  in  childhood  and  early  life  are  some- 
times started  by  overwork  at  school,  but  usually  no  especial  cause 
can  be  found.     When  they  begin  after  maturity,  a  history  of 


126  DISEASES   OF   THE   NERVOUS   SYSTEM. 

excesses  in  work,  injury,  shock,  or  exhausting  disease  is  found. 
Migrainous  patients  usually  have  some  refractive  disorder  of  the 
eye  or  a  weakness  of  eye  muscles,  and  this  condition  is  one  factor 
in  bringing  on  or  keeping  up  the  headaches. 

Sympto?n.s.— The  patient  for  several  days  may  feel  a  sense  of 
malaise  and  depression;  usually,  however,  the  prodromal  stage 
lasts  only  a  few  hours  or  a  day.  The  attack  often  comes  on  in 
the  morning  and  gradually  increases  in  frequency  until  the  vic- 
tim has  to  give  up  work  and  lie  down.  The  pain  starts  in  one 
side  of  the  head,  usually  in  the  forehead,  but  often  in  the  occiput. 
It  increases  and  finally  may  involve  the  whole  head.  The 
pain  is  of  a  tense,  throbbing,  blinding  character,  increased  by 
jars,  light,  and  noises.  It  is  accompanied  by  dimness  of  vision, 
often  by  flashes  of  light  or  dark  or  light  spots  variously  colored 
floating  before  the  eyes.  Restriction  of  the  visual  field,  sometimes 
in  the  form  of  hemianopsia,  may  occur.  Vertigo,  tinnitus  aurium, 
confusion  of  ideas,  feeling  of  stupor,  disturbances  of  memory,  are 
not  uncommon ;  nausea  and  even  vomiting  are  the  rule.  The  vom- 
ited matter  is  at  first  chiefly  mucus,  but  it  may  later  get  yellow 
and  bitter  from  the  presence  of  bile.  Hence  the  term  "  bilious 
headache,"'  which  is  an  improper  one,  because  the  bile  is  only  the 
result  of  retrostaltic  action  from  the  vomiting.  Migraine  is  not 
the  result  of  gastric  or  liver  disorder. 

The  patient's  face  usually  is  pale  and  gives  the  evidence  of 
acute  suffering.  The  flushed  face  is  very  rare;  the  distinction 
between  angiospastic  or  pallid  migraine  and  angioparalytic  or 
congestive  migraine  is  not  of  clinical  value. 

The  pulse  is  small  and  hard  and  may  be  lessened  in  rapidity. 

The  temperature  often  rises  in  children. 

The  attack  lasts  from  six  to  twelve  or  twenty-four  hours,  occa- 
sionally even  two  or  three  days.  As  the  intensity  of  the  pain  les- 
sens the  patient  sinks  to  sleep,  and  awakens  next  morning  feeling 
refreshed  and  better  than  before  the  attack. 

The  attacks  occur  at  varying  periods,  fortnightly  or  monthly, 
and  even  weekly.  In  women  they  often  occur  during  men- 
struation. Some  women  are  entirely  free  from  them  during  preg- 
nancy. At  about  the  time  of  the  menopause  in  women,  and  at 
about  the  same  time  of  life  in  men.  the  disease  lessens  in  sever- 
ity and  as  a  rule  disappears.  Some  form  of  neuralgia  or  some 
neurosis  in  rare  cases  takes  its  place. 

Complicating  Sijmptoms.—Vsivtml  oculo-motor  paralysis,  tem- 
porary aphasia,  slight  hemiplegia,  hemi-numbness,  peculiar  odors 
or  tastes,  convulsive  movements  of.  the  body,  almost  resembling 
epileptic  attacks,  occur. 

Cases  presenting  these  symptoms  are  rare.  When  they  occur 
in  one  case,  hoAvever,  they  always  occur  in  each  attack  unless  it 
is  modified  by  treatment. 


DISEASES   OF   THE   CRANIAL  NERVES.  127 

Vicarious  Attacks.— Migvuine  is  soinetiines  associated  with  epi- 
lepsy, locomotor  ataxia,  or  insanity;  that  is  to  say,  persons  in 
early  life  have  had  migraine  and  later  developed  the  diseases 
mentioned.  The  relation  between  these  diseases,  however,  is  not 
so  close  as  some  writers  would  lead  us  to  infer.  The  attack  of 
migraine  can  be  sometimes  replaced  by  an  attack  of  gout,  or 
visual  disorders,  or  other  sensory  symptoms,  or  even  by  an  oculo- 
motor paralysis.  Sometimes,  instead  of  a  fully  developed  attack 
the  patient  has  a  sense  of  mental  depression,  with  confusion  of 
ideas.  Cases  have  been  reported  in  which  acute  mania  took  the 
jjlace  of  the  headache. 

'Types. — AVriters  have  described  the  angioparalytic  and  angio- 
spastic types ;  also  the  typical,  subtypical,  and  supratypical ;  and 
finally  the  ordinary  type  and  the  ophthalmic  type.  Practically 
we  find  two  classes : 

(1)  The  typical,  associated  with  visual  disorders  and  having 
most  of  the  symptoms  described  above. 

(2)  The  irregular  or  mixed  type  in  Avhich  with  many  symptoms 
of  ordinary  migraine  there  is  a  history  of  rheumatic  influences, 
and  often  of  anaemia  or  dyspepsia.  These  are  cases  of  a  true  mi- 
grainous aflfection  complicated  Avith  some  form  of  symptomatic 
headache,  such  as  has  been  already  described.  The  mixed  or  ir- 
regular migraines  are  important  to  recognize,  for  they  call  for 
special  treatment.  They  occur  almost  altogether  in  women ;  the 
attacks  are  often  associated  with  weather  changes  and  may  be  of  a 
neuralgic  character.  Many  women  have  their  sick-headaches  and 
their  neuralgic  headaches,  so  called,  and  have  to  distinguish  be- 
tween them.  In  mixed  attacks  the  face  is  usually  also  pale,  the 
eyes  are  not  suffused,  nor  is  there  any  visual  or  aural  disturbance, 
as  in  migraine.  Sometimes  the  pain  remains  in  the  occipital  nerves, 
and  1  have  met  with  one  patient  who  localizes  her  pain  there  en- 
tirely, and  who  always  vomits  during  the  attack. 

FatJioIog I/.— The  seat  of  the  disease  is  chiefly  in  the  intracra- 
nial branches  of  the  fifth  nerve  and  of  the  pneumogastric ;  the 
upper  cervical  nerves,  however,  are  often  involved.  There  are 
no  morbid  anatomical  changes  known. 

The  most  plausible  theory  of  the  disease  is  that  it  is  a  fulgurat- 
ing neurosis,  in  which  there  are  periodical  discharges  of  nerve 
force,  or  nerve  storms.  The  seat  of  the  discharge  is  perhaps 
in  the  cerebral  cortex,  but  more  likely  in  the  primary  sensory 
centres,  i.e.,  the  root  ganglia  of  the  fifth  and  vagus  nerves.  The 
disease  is  certainly  not  in  the  sympathetic  system,  as  was  once 
taught. 

Diagnosis.— The  diagnosis  is  based  upon  the  hereditary  his- 
tory, the  periodicity  and  seat  of  the  attacks,  the  nausea,  the  com- 
plicating visual  and  other  sensory  symptoms.     It  should  not  be 


128  DISEASES   OF  THE   NERVOUS   SYSTEM. 

forgotten  that  the  same  patient  may  have  migraine  and  other 
neuralgias,  or  may  have  also  an  organic  brain  or  renal  disease. 

TreatmeJit.—Frophi/laxin.— Children  of  families  in  which  this 
neurosis  exists  should  be  carefully  watched  during  the  ages  be- 
tween five  and  tw^enty.  The  eyes  and  nose  should  be  examined. 
They  should  not  be  subjected  to  excessive  mental  or  visual  strain, 
and  if  attacks  develop  they  should  be  promptly  treated.  The  appli- 
cation of  glasses  should  be  considered,  but  not  hastily  adopted. 

As  regards  constitutional  treatment,  the  best  measures  for  cur- 
ing a  case  of  migraine  consist  in  correcting  any  visual  or  nasal 
defect,  such  diet  and  exercise  as  secure  tone  to  the  nerves,  and 
the  continuous  use  internally  of  bromide  of  potassium,  nitrogly- 
cerin, cannabis  indica,  or  arsenic. 

Of  the  above  drugs,  cannabis  indica,  either  with  or  without 
arsenic,  is  the  most  trustworthy,  while  the  bromides  are  the 
least.  The  hemp  should  be  given  in  large  doses  and  for  a  long 
time,  gr.  i  to  gr.  i.  ter  in  die.  Much  stress  is  laid  by  some  upon 
ocular  muscular  insufficiencies,  and  I  believe  that  such  condi- 
tions should  be  remedied,  but  place  little  confidence  in  them 
alone.  On  the  other  hand,  the  correction  of  small  or  large  de- 
grees of  astigmatism  and  hyj)ermetropia  sometimes  produces 
surprisingly  good  results.  The  reported  cure  of  numerous  cases 
of  migraine  by  treatment  of  nasal  hypertrophies  and  catarrh 
should  not  excite  too  much  confidence  in  such  measures.  In  fact, 
since  migraine  is  a  constitutional  neurosis,  one  cannot  expect 
permanent  results  from  removing  reflex  irritants  alone.  The 
daily  use  of  a  strong  galvanic  current  four  to  eight  milliamperes 
(eight  to  ten  cells)  for  ten  minutes  is  useful. 

For  the  relief  of  the  attack  the  following  drugs  may  be  given  : 
Salicylate  of  soda,  gr.  xx. ;  caffeine,  gr.  ij.  to  v.,  with  benzoate  of 
soda,  gr.  x. ;  antipyrine,  gr.  v.  q.  i  h. ;  phenacetin,  gr.  x.  to  xv.  or 
more;  powdered  guarana,  gr.  xx. ;  menthol,  gr.  v.. to  x.  in  hot 
water ;  muriate  of  ammonia,  gr.  xxx.  to  3  i. ;  bromide  of  potassium, 
gr.  XX.  Antipyrine  and  phenacetin  are  the  most  certain  of  the 
above  drugs,  but  they  lose  their  effect  after  a  time,  as  do  almost 
all  the  other  drugs,  and  finally  patients  give  up  treatment  or 
resort  to  codeia  or  morphine.  Chloral  and  a  hot  foot-bath  break 
up  attacks  sometimes. 

Locally  galvanic  currents  are  sometimes  lielpful,  and  so  are 
static  sparks.  Hot  applications  and  pencilling  with  menthol  give 
relief  to  some.      Quiet  and  rest  are  spontaneously  resorted  to. 

Neuralgias  of  the  Trigemixus.— The  trigeminal  nerve  is 
subject  to  two  types  of  neuralgia,  viz. : 

1.  The  symptomatic  form. 

3.  Tic  douloureux. 

1.  The  symptomatic  7ietiralgias  are  by  far  the  most  frequent. 


DISEASES   OF   THE   CRANIAL   NERVES. 


129 


They  are  called  supra-orbital,  infra-orbital  or  supra-maxillary, 
iiifra-maxillary  or  dental,  and  mixed  forms.  The  most  common 
type  is  the  supra-orbital ;  next,  the  mixed  form. 

Miologjj.— The  female  sex  is  oftenest  affected ;  most  cases  are 
seen  in  the  first  half  of  life;  most  attacks  occur  in  the  winter  and 
spring.  The  left  side  is  oftener  afifected.  The  second  and  tliird 
branches  of  the  fifth  nerve  are  most  susceptible  to  rheumatic  in- 
fluences, the  first  branch  to  malarial  and  septic  poisons.  .  Dental 
disorders  naturally  are  frequent  factors  in  neuralgia  of  the  sec- 
ond and  third  branches.  Anajmia,  ex^josure,  child-bearing,  and 
other  depressing  influ- 
ences are  factors  in  caus- 
ing these  neuralgias.  Oc- 
ular and  nasal  disease 
may  cause  pain  in  the  su- 
pra-orbital nerv^e.  Gout, 
diabetes,  syphilis,  mala- 
ria, hysteria,  epilepsy, 
trauma,  rheumatism,  all 
may  be  factors  in  causing 
trigeminal  neuralgias. 

Si/ )nptoms.— The  pains 
of  trigeminal  neuralgia 
are  sharp  and  intense, 
with  exacerbations  and 
remissions.  The  pain  of- 
ten lasts  for  days  with- 
out entirely  ceasing.  It 
then  goes  away  and  may 
not  return  for  a  long 
time.  The  characteristic 
of  neuralgia  is  that  it 
stays  till  its  cause  is  re- 
moved. In  suj)ra-orbital 
neuralgia  there  is  some- 
times great  oedema  of  the  lids  and  the  parts  about,  together  Avith 
sulTusion  of  the  eyes.  There  are  tender  points  over  the  course 
of  the  nerves.  The  common  points  in  supra-orbital  neuralgia 
are  supra-orbital,  palpebral,  and  nasal;  in  infra-orbital  neural- 
gia, nasal,  malar,  and  gingival;  in  infra-maxillary  neuralgia, 
inferior  dental  and  temporal.  In  the  mixed  forms  we  find 
various  combinations  of  the  above.  There  is  often  also  a  tender 
point  over  the  parietal  eminence  and  vertex. 

The  pain  may  radiate  to  the  ear  or  occiput  or  it  may  be  located 
in  the  orbit.     Dental  irritation  may  also  cause  an  otalgia  or  a 
neuralgia  in  the  upper  branches  of  the  fifth. 
9 


Fig.  66.— Showing  the  Distribution'  op  the 
Sensory  Nerves  op  the  Face.  7,  //,  ///,  First, 
second,  and  third  branches  of  the  fifth.  The 
shaded  part  is  suppHed  by  the  cervical  nerves; 
2  C.  a.  br.,  second  cervical  anterior  branch; 
2  C.  p.  br.,  second  cervical  posterior  branch. 


130  DISEASES   OF  THE   NERVOUS   SYSTEM. 

There  is  sometimes  a  dilatation  of  the  pupil,  and  in  severe 
cases  a  reflex  facial  spasm  occurs. 

Tic  Douloureux  {Frosoi)algia,  FothergilVs  Neuralgia,  Epilep- 
tiform Neuralgia). — Tic  douloureux  is  a  special  form  of  trigem- 
inal neuralgia,  unusually  severe  in  its  symptoms  and  obstinate  in 
its  course.  It  ought  to  be  distinguished  sharply  from  the  ordinary 
forms  of  trigeminal  neuralgia.  These  latter  are  symptomatic 
pains  almost  altogether;  Avhile  tic  douloureux  is  an  idiopathic 
disorder,  or  at  least  is  one  dependent  uj^on  changes  in  the  nerve 
itself. 

Etiology. — It  occurs,  as  a  rule,  in  persons  who  are  over  forty, 
and  is  seen  in  the  very  aged.  It  is  indeed  the  only  neuralgia 
which  old  people  have.  It  is  brought  on  by  exposure,  overwork, 
and  depressing  influences;  sometimes,  jjerhaps,  by  local  dis- 
eases of  the  teeth  and  jaws.  It  occurs  in  men  and  women  in 
about  equal  frequency,  in  my  experience. 

Symptoms.  —It  is  characterized  by  intense,  darting  pains  which 
usually  start  in  the  ui3per  lip  and  by  the  side  of  the  nose.  From 
here  they  radiate  through  the  teeth  or  into  the  eye  and  over  the 
temi)le,  brow,  and  head.  They  are  confined  to  one  side  of  the 
head.  During  a  paroyxsm  the  face  usually  flushes,  the  eyes 
water,  the  nose  runs,  and  the  patient  assumes  an  expression  of 
the  greatest  agony.  The  attack  lasts  for  a  few  minutes,  then 
becomes  somewhat  less,  but  the  pain  rarely  ceases  entirely.  A 
breath  of  cold  air,  speaking,  eating,  putting  out  the  tongue — all 
bring  on  paroxysms.  The  pains  are  worse  in  winter  and  often 
become  less  or  cease  during  summer.  Occasionally  they  come  on 
for  a  few  months  every  year,  usually  during  the  spring. 

Spasmodic  movements  of  the  face  may  be  associated  with  the 
pain. 

Examination  rarely  reveals  any  objective  trouble,  but  in  a  few 
cases  some  anesthesia  may  be  noted. 

Pathology. — The  disease  is  usually  a  degenerative  one,  and 
probably  is  due  to  irritative  and  atrophic  processes  occurring  in 
the  nerve.  A  low  grade  of  neuritis,  perhaps  from  alveolar  dis- 
ease, has  been  found  sometimes,  but  as  a  rule  the  nerve  does  not 
appear  much  changed.  The  arteries  supplying  the  nerve,  how- 
ever, often  undergo  the  changes  of  endarteritis,  their  calibre  is 
much  lessened,  and  the  nerve  cannot  get  its  proper  supply  of 
blood.  Thus  an  obliterative  arteritis  underlies  some  cases  of  the 
disease. 

Treatment. — In  cases  which  occur  in  old  people,  the  use  of 
nitroglycerin  given  in  doses  of  gr.  ynir  Q-  2  h.  sometimes  has  a 
happy  effect.  The  best  single  remedy,  however,  is  undoubtedly 
crystalline  aconitia  given  in  doses  of  gr.  ^i^  until  its  physiological 
effect  is  obtained.     After  this  come  injections  of  cocaine.     Be- 


DISEASES   OF  THE   CRANIAL  NERVES.  131 

sides  these  measures,  galvanism  daily,  iodide  of  potassium  in 
large  doses,  gelsemium,  croton  chloral,  codeine,  external  applica- 
tions of  menthol,  freezing  with  chloride  of  metliyl,  and  heat— all 
may  be  found  useful.  The  connnon  practice  of  pulling  out  all 
the  teeth  is  almost  always  unsuccessful,  and  ought  not  to  be  un- 
dertaken without  specially  good  reason.  Tonics  containing  iron, 
phosphorus,  quinine,  or  arsenic  are  generally  helpful,  and  should 
always  be  given  after  a  course  of  specifics.  In  younger  patients 
the  remedies  recommended  under  the  head  of  Migraine  and  Head- 
ache may  be  given.  Change  to  a  warm,  equable  climate  may  be 
tried ;  it  is  not  a  certain  resource. 

Finally,  surgical  interference  may  be  necessary.  The  removal 
of  the  nerve  at  as  deep  a  point  as  possible  is  the  only  operation 
to  be  seriously  entertained.  This  sometimes  causes  cure,  but,  as 
a  rule,  the  pain  comes  back  in  six  or  twelve  months.  Even  such 
a  respite,  however,  is  often  gladly  seized  upon.  Removal  of  the 
Gasserian  ganglion  has  been  attempted  with  some  success.  Liga- 
ture of  the  common  carotid  has  been  tried  also,  but  of  late  years 
the  operation  has  been  generally  abandoned.  Simple  drilling 
out  of  the  infra-orbital  nerve  with  a  dental  probe  made  of  jjiano 
wire  has  given  long  relief. 

There  are  numerous  methods  of  operating  upon  the  different 
branches  of  the  trigeminus.  For  buccal  neuralgia,  Zuckerkandl 
has  devised  a  method.  For  superior  maxillary  neuralgia,  the 
method  of  Carnochan,  modified  by  Abbe,  is,  in  my  opinion,  the 
best.  Others  favor  Langenbeck's  method.  Ullmann,  Mikulicz, 
Obalinski,  and  many  others  have  devised  special  methods. 

Hartley,  of  New  York,  has  devised  an  operation  by  which  he 
enters  the  middle  fossa  through  an  opening  in  the  temporal  bone, 
thus  reaching  the  root  of  the  nerve. 

Trigeminal  PARiESTHESiA. — Sometimes  persons  suffer  from 
peculiar  numbness,  thrilling,  or  formication  in  the  course  of  the 
trigeminus. 

The  sensation  may  be  nearly  constant  and  excessively  annoy- 
ing.    It  never  amounts  to  actual  pain. 

It  occurs  in  anaemic,  nervous,  and  hysterical  persons.  It  is  to 
be  regarded  as  an  abortive  form  of  neuralgia,  and  so  treated. 

Trigeminal  Anaesthesia. — This  occurs  from  various  path- 
ological lesions  in  the  course  of  the  nerve  or  in  its  nuclei. 

The  most  connnon  organic  cause  is  syphilitic  disease  of  the 
membranes  at  the  base  of  the  brain. 

Trigeminal  anaesthesia  occurs  together  with  anaesthesia  of 
other  areas  in  hysteria  and  in  organic  disease  of  the  nerve  centres. 
It  is  sometimes  noted  in  tic  douloureux  and  facial  hemiatrophy. 

Herpes,  flushing,  pallor,  lachrymation,  sdli cation  are  all  symp- 
toms of  disturbance  of  the  trophic,   vasomotor,  and   secretory 


132  DISEASES   OF   THE   NERVOUS   SYSTEM. 

fibres  running  in   the  trigeminal  nerve.     They  are  usually,  if 
pathological,  only  concomitant  symptoms  of  other  diseases. 

The  diseases  of  the  motor  branch  of  the  trigeminus  are  rare, 
and  generally  symptomatic  of  some  more  general  disorder. 

Trismus  (lock-jaw)  is  the  only  important  independent  affec- 
tion of  this  motor  nerve.  It  is  a  tonic  spasm  of  the  muscles  of 
mastication. 

Etiology. — It  occurs  in  infants,  usually  through  infection  from 
the  umbilicus.  It  is  then  known  as  trismus  nascentium.  It  forms 
part  of  the  symptoms  of  tetanus.  It  may  be  symptomatic  of 
brain  disease,  and  forms  one  of  the  manifestations  of  the  epilep- 
tic fit.  There  may  be  a  reflex  trismus  from  irritations  of  the  teeth 
and  jaw,  and  froiu  gastro-intestinal  trouble.  ]S"euritis  and  hysteria 
are  causes  of  trismus. 

Symptoms. — There  is,  as  shown  above,  a  symptomatic,  an  in- 
fectious, a  reflex,  a  neuritic,  and  a  hysterical  trismus.  In  all,  the 
symptoms  are  very  manifest.  The  jaws  are  firmly  locked  and 
the  masseters  and  temporals  stand  out.  If  the  disease  is  uni- 
lateral, which  is  rarely  the  case,  the  lower  jaw  is  pushed  over 
toward  the  sound  side. 

The  treatment  of  both  tonic  and  clonic  spasms  depends  upon 
the  cause.  Symptoms  tically,  morphine  is  to  be  given,  and  later 
the  antispasmodics,  such  as  the  bromides.  In  rheumatic  cases 
hot  applications  and  diaphoretics  are  indicated. 


Diseases  of  the  Facial  ]S^erve. 

The  facial  nerve  being  motor,  its  diseases  are  spasmodic  and 
paralytic.  The  two  common  types  are  facial  tic  and  facial  palsy, 
but  there  are  other  minor  forms. 

The  sapsmodic  disorders  are  (1)  diffuse  facial  spasm  or  mimic 
tic  and  (2)  spasm  of  single  branches,  including  {a)  blepharospasm 
and  (b)  nictitating  spasm. 

Facial  Spasm  (Mlmic  Tic).— This  is  a  disease  characterized 
by  intermittent,  involuntary  twitchings  of  the  facial  muscles.  It 
is  always  chronic  and  generally  unilateral. 

Etiology. — It  is  a  disease  of  middle  and  later  life,  and  occurs 
oftener  in  women;  there  is  usually  a  neuropathic  constitution ;  it 
is  not  hereditary.  The  exciting  causes  are  anxiety,  shock,  injury, 
and  exposures.  It  often  has  a  refl.ex  cause,  usually  from  irrita- 
tion of  some  branch  of  the  trigeminus  or  the  cervico-brachial 
nerves,  rarely  from  eye  strain.  Organic  diseases,  such  as  tumors 
and  softening,  affecting  the  nerve  nucleus  in  the  pons  or  the 
cerebral  centres,  cause  a  symptomatic  tic,  but  not  the  true  disease. 


DISEASES   OF   THE   CRANIAL  NERVES.  133 

Thus  we  may  have  a  post-heraiplegic  tic  or  a  tic  due  to  cortical 
lesion  and  associated  with  epilepsy. 

True  facial  tic  may  be  caused  by  irritation  or  disease  of  the 
nerve. 

Symptoms.— The  disease  usually  begins  slowly  and  the  orbic- 
ulis  muscle  and  zygomatic!  are  earliest  affected.  It  rarely  goes 
above  the  eyebrows,  i.e.,  to  the  corrugator  supercilii  and  fron- 
talis. The  lower  branch  of  the  facial  is  little  affected.  The 
sjiasm  is  a  clonic  one,  the  muscles  of  the  face  are  affected  by  a 
series  of  lightning-like  twitches,  with  intervals  of  rest.  Some- 
times the  contraction  becomes  tonic  and  lasts  several  seconds 
or  more.  There  is  no  pain.  The  spasm  is  increased  by 
emotions,  nervous  excitement,  conversation,  exposure  to  light 
and  cold,  and  is  at  its  worst  when  the  patient  himself  is  most 
depressed.  It  is  a  very  good  gauge  of  the  general  nervous  sta- 
bility of  the  patient. 

There  is  no  paralysis  or  atrophy,  and  there  are  no  secretory 
or  troi^hic  symptoms.  The  taste  fibres  are  rarely  involved, 
though  occasional  subjective  sensations  of  taste  have  been  felt. 

The  electrical  irritability  is  either  unchanged  or  slightly  in- 
creased. 

Associated  movements  of  the  eyes,  of  the  jaw  muscles  and 
cheek  muscles  are  sometimes  seen.  Pressure  over  the  motor 
points  of  the  nerve  will  sometimes  arrest  the  movements  for  a 
time.  The  disease  is  a  unilateral  one.  It  lasts  for  years  and 
even  for  the  lifetime. 

Pathology. — There  is  no  known  anatomical  change  in  idio- 
pathic cases.  The  disease  is  allied  in  character  to  wry-neck 
and  other  chronic  tics.  It  is  a  motor  correlative  to  the  severe 
neuralgias  like  tic  douloureux.  It  is  sometimes  a  pure  reflex 
neurosis  from  ocular  or  dental  irritations. 

Diagnosis. — Idiopathic  facial  spasm  is  chronic,  unilateral,  un- 
accompanied by  pain  or  paralysis.  It  is  distinguished  from  facial 
spasms  of  organic  origin  by  the  fact  that  the  latter  always  have 
some  other  symptoms.  Thus  facial  habit-chorea  is  bilateral  ■ 
spasm  from  cortical  disease  is  attended  by  disturbance  of  con- 
sciousness and  comes  on  in  paroxysms;  the  spasm  occurring 
after  hemiplegia  is  usually  tonic,  a,nd  so  is  hysterical  facial  spasm. 

Prognosis.— The  disease  is  in  most  cases  incurable,  especially 
after  it  has  lasted  some  time.  If  a  reflex  cause  exist,  the  progno- 
sis is  better.     Life  is,  however,  never  endangered  by  it. 

Treatment.— The  most  important  thing  is  attention  to  the 
general  health,  removal  of  all  depressing  influences,  rest,  and  free- 
dom from  excitement.  Among  specific  remedies  arsenic,  the 
bromides,  cannabis  indica,  gelsemium,  conium,  hyoscyamus, 
strychnia,  codeine,  and  morphine  are  recommended.     Morphine  is 


134  DISEASES   OF   THE   NERVOUS   SYSTEM. 

useful,  but  must  be  tried  carefully  and  in  small  doses.  Conium 
lessens  the  spasm,  but  this  druj?  has  to  be  given  in  large  doses 
and  is  not  entirely  free  from  danger.  Hyoscine  and  gelsemium 
sometimes  do  good.  Careful  examination  of  the  teeth,  eyes,  nose, 
stomach,  and  uterus  for  reflex  irritation  is  imperative. 

Galvanism,  if  carefully  and  persistently  applied,  almost  al- 
ways helps.  It  should  be  given  daily.  Various  methods  are  de- 
scribed. The  best  way  is  to  place  the  negative  pole  on  the  ster- 
num or  back  of  the  neck,  and  the  i^ositive  pole  over  each  motor 
point  of  the  nerve  for  one  to  two  minutes,  then  over  the  occiput 
and  over  the  facial  cortical  area  for  the  same  time.  Currents  of 
two  to  five  milliamperes  should  be  used.  Neurectomy  of  the 
supra-orbital,  continuous  pressure  on  the  motor  points,  stretch- 
ing the  nerve  itself,  are  all  measures  which  may  be  considered 
valueless. 

Freezing  the  skin  over  the  nerve  with  chloride  of  methyl  has 
been  recommended  by  Mitchell. 

Blistering  and  cauterization  are  needless  inflictions.  The  an- 
sesthetization  of  the  conjunctiva  w^ith  cocaine  is  often  hell^ful, 
both  in  diagnosis  and  treatment. 

Blepharospasm  is  the  name  given  to  a  tonic  spasm  of  the 
orbicularis  palpebrarum.  It  is  generally  caused  by  diseases  of 
the  eye,  and  its  nature  and  treatment  are  matters  belonging  to 
ophthalmology.     It  is  a  rare  symptom  of  hysteria. 

Nictitating  or  wixkixg  spasm  is  a  clonic  spasm  of  the  obic- 
ularis,  and  usually  forms  part  of  habit-chorea  or  is  a  symptom  of 
hvsteria. 


Facial  Palsies. 

The  paralyses  of  the  facial  nerve  may  be  due  to  lesions  that 
are  central,  nuclear,  meningeal,  or  peripheral. 

Facial  fjalsy  of  central  origin  is  almost  invariably  an  accom- 
paniment of  hemiplegia  and  is  due  to  hemorrhage,  softening, 
inflammation,  or  tumor  of  the  brain.  The  lower  two  branches  of 
the  facial  are  chiefly  involved. 

Facial  palsy  of  nuclear  origin  is  very  rare  and  is  an  accom- 
paniment of  glosso-labial  palsy,  of  diphtheritic  palsy,  or  of  gross 
lesions  of  the  pons. 

Facial  palsy  of  meningeal  origin  is  due  to  tumors,  meningitis 
or  fracture  of  the  base  of  the  brain  and  is  accompanied  by  lesion 
of  other  cranial  nerves.  Syphilis  is  the  most  important  factor 
here.     All  these  forms  are  simply  pa-rt  of  other  diseases. 

Peripheral  facial  palsy  (Bell's  palsy)  is  the  common 
type  of  facial  paralysis. 

Etiology. — The  typical  cases  of  this  disease  are  due  to  expo- 


DISEASES   OF  THE   CRANIAL  NERVES.  135 

sure  and  rheumatic  influences.  Males  are  oftener  affected,  and 
the  connnon  age  is  between  twenty  and  forty.  *  It  is  more  fre- 
quent in  the  winter  and  in  temperate  chmates.  It  is  not  hered- 
itary. A  neuropathic  tendency  and  the  rheumatic  diatheses 
predispose  to  it.  Syphihs  rarely  causes  an  isolated  facial  palsy; 
in  fact,  it  is  apt  to  leave  this  nerve  alone  (Hutchinson). 

Facial  palsy  may  occur  in  multiple  neuritis  and  in  locomotor 
ataxia.  Non-typical  and  accidental  cases  of  peripheral  facial 
X^alsy  are  due  to  injuries,  fracture  of  the  petrous  bone,  or  ear 
disease.  Forceps  pressure  in  difficult  labor  causes  some  cases,  and 
a  very  few  have  been  congenital. 

^ljmx)toms.—The  disease  comes  on  rather  suddenly,  and  reaches 
its  height  within  a  few  hours  or,  at  most,  two  or  three  days.  Pre- 
ceding and  accompanying  the  onset  there  may  be  some  pain  about 
the  ears  and  a  little  swelling  is  sometimes  seen. 

The  patient  feels  a  subjective  discomfort  on  the  paralyzed 
side  of  the  face.  He  finds  that  he  cannot  completely  shut  the 
eye ;  if  he  tries  to  chew  on  the  affected  side,  food  gets  between  the 
teeth  and  cheek.  He  cannot  pucker  the  lips,  and  his  speech  is  a 
little  muffled.     The  appearance  of  the  face  is  most  characteristic. 

On  the  affected  side  the  wrinkles  are  smoothed  out,  the  angle 
of  the  mouth  is  lower,  the  mouth  is  drawn  at  first  to  the  sound 
side,  and  owing  to  this  distortion  the  tongue  appears  not  to  be 
protruded  straight.  In  laughing  or  other  emotional  movements 
of  the  face,  the  trouble  is  most  clearly  brought  out.  But  the 
most  characterized  appearance  is  produced  by  telling  the  patient 
to  shut  the  eyes  tightly  and  draw  out  the  angles  of  the  mouth 
so  as  to  show  the  teeth.  The  eye  on  the  palsied  side  is  not  closed, 
and  the  eyeball  turns  up,  showing  the  white  of  the  eye.  This 
test  of  the  palsy  is  better  than  any  examination  of  the  wrinkles 
and  folds  of  the  face,  for  in  children  and  in  the  young  and  plump 
these  differences  in  the  two  sides  of  the  face  are  not  very  marked, 
especially  in  the  slighter  cases. 

The  nostril  on  the  affected  side  does  not  expand  on  forced 
inspiration;  the  eye  is  apt  to  be  watery  and  the  conjunctiva 
somewhat  injected. 

If  the  disease  extend  well  up  into  the  Fallopian  canal  so  as 
to  involve  the  nerve  to  the  stapedius,  that  nuiscle  is  paralyzed, 
the  tensor  tympani  acts  unopposed,  the  drum  is  tightened,  and 
unusual  sensitiveness  to  sounds  results.  This  is  rare,  however; 
most  of  the  ear  symptoms  in  facial  jjalsy  being  due  to  a  concomi- 
tant disorder  of  the  tympanum  or  the  acoustic  nerve. 

If  the  disease  involve  the  nerve  between  the  geniculate  gan- 

*  Among;  14  cases  there  were  9  males.  5  females.  The  ages  were:  Fifteen  to 
twenty,  2:  twenty-one  to  thirty,  7;  thirty-one  to  forty,  3;  forty-one  to  fifty,  2.  Left 
side,  9;  right,  5. 


136  DISEASES   OF  THE   NERVOUS   SYSTEM. 

glion  and  the  point  where  the  chorda  tympani  is  given  off  (see 
Fig.  68),  some  loss  of  taste  follows,  and  this  is  a  frequent  symptom, 
but  not  one  of  long  duration.  If  the  disease  is  located  more  cen- 
trally than  the  geniculate  ganglion  or  more  peripherally  than  the 
chorda  nerve,  taste  is  not  involved.  Usually,  when  there  is  no 
taste  involvment,  it  is  because  the  lesion  is  peripheral.  By  an 
examination  of  the  taste  sense  and  of  the  hearing,  the  location 
of  the  trouble  can  be  accurately  made  out. 

After  a  few  weeks  some  wasting  of  the  face  may  be  noted,  but 
this  is  never  v^ery  great. 

The  electrical  reactions  are  characteristic  and  imiDortant,  since 
typical  or  partial  degeneration  reactions  can  usually  be  observed. 
For  a  few  days  there  is  an  increase  in  irritability  of  the  mus- 
cles to  both  faradic  and  galvanic  currents.  This  is  followed  by  a 
gradual  loss  or  diminution  in  faradic  irritability,  while  the  gal- 
vanic irritability  remains  sometimes  increased  for  a  while  and 
then  falls.  At  the  same  time  a  reversal  of  i)oles  and  a  sluggish 
contraction,  particularly  the  latter,  may  be  noted.  At  the  end 
of  five  or  six  weeks  faradic  irritability  ought  to  begin  to  return. 
Great  variations  are  found  in  the  electrical  reactions  dependent 
upon  the  severity  of  the  case. 

If  the  disease  lasts  for  two  months  or  more  and  the  palsy  is 
not  a  complete  one,  secondaiy  contractures  begin  to  appear.  The 
mouth  now  becomes  drawn  to  the  affected  side,  and  the  naso- 
labial fold  becomes  deeper  than  that  on  the  sound  side.  In  smil- 
ing or  speaking  or  other  facial  movements  there  is  an  excess  of 
movement  on  the  paralyzed  side,  the  teeth  and  upper  gums  in 
particular  showing  abnormally. 

Pathology. — The  disease  in  its  typical  form  is  due  to  a  diffuse 
neuritis  of  rheumatic  character.  This  attacks  the  peripher^^  of 
the  nerve  in  the  face  and  extends  rapidly  up  into  the  Fallopian 
canal  as  far  as  the  geniculate  ganglion.  The  inflammation  some- 
times attacks  most  the  peripheral  filaments ;  at  other  times  it  is 
more  central.  The  old  idea  that  it  was  always  a  perineuritis  of 
the  nerve  in  the  Fallopian  canal  is  incorrect  (Minkowski). 

Diagnosis. — The  recognition  of  the  palsy  is  made  easy  by 
causing  the  patient  to  contort  the  face.  In  children  it  requires 
more  care  to  detect  the  side  affected. 

It  is  important  to  determine  whether  the  palsy  is  cerebral, 
nuclear,  basilar,  or  peripheral.  If  the  cause  is  cerebral,  the  upper 
branch  of  the  nerve  is  little  affected  and  the  patient  can  close  the 
eye.     The  nerve  and  muscles  show  no  degenerative  reactions. 

Nuclear  palsy  is  A^ery  rare  and  is  accompanied  Avith  other 
symptoms,  especially  those  of  involvement  of  other  cranial  nerves. 
A  history  of  diphtheria,  lead  palsy,  or  bulbar  paralysis  is  ob- 
tained. 


DISEASES   OF  THE   CRANIAL   NERVES.  137 

In  palsies  due  to  lesions  at  the  base  of  the  brain  such  as 
gununy  meningitis,  the  auditory  and  other  cranial  nerves  are  in- 
volved and  there  are  signs  of  brain  syphilis.  By  testing  the 
sense  of  taste  and  hearing  the  location  of  the  peripheral  trouble 
can  be  made  out  (Fig.  68).  Thus  if  there  be  loss  of  taste  on  the 
anterior  two-thirds  of  the  tongue,  the  lesion  must  be  between 
the  geniculate  ganglion  and  the  j^oint  at  which  the  chorda  tym- 
pani  is  given  off.  If  the  taste  be  not  involved,  the  lesion  must 
be  central  or  peripheral  of  the  part  of  the  nerve  which  includes 
the  chorda.  Practically  in  most  cases  it  is  peripheral  to  it.  If 
central,  the  disease  is  usually  of  syphilitic  or  tubercular  origin; 
the  palsy  is  severe  and  the  loss  of  ability  to  close  the  eye  very 
great. 

Prognosis. — The  prognosis  of  peripheral  palsy  (Bell's)  is  good, 
although  an  absolutely  complete  recovery  often  does  not  take 
place. 

In  syphilitic  cases  the  prognosis  is  not  so  good,  though  patients 
often  recover.  In  central  palsies  the  prognosis  is  the  worst,  be- 
cause the  lesion  usually  does  not  disai^pear.  However,  the  cen- 
tral cases  are  from  the  beginning  of  a  mild  type,  and  give  an- 
noyance mainly  from  the  secondary  contractures. 

BelFs  palsy  usually  lasts  three  to  five  months.  Occasionally 
there  are  mild  cases  that  get  well  within  a  month.  The  progno- 
sis as  to  duration  is  much  helped  by  a  close  study  of  the  electri- 
cal reactions.  In  proportion  as  the  degeneration  reaction  is  com- 
plete and  persistent  the  outlook  is  bad. 

Treatment. — In  the  acute  peripheral  cases  the  patient  should 
be  treated  promptly  and  thoroughly.  He  should  be  given  a  di- 
nretic  and  purgative  and  a  blister  should  be  placed  over  the  exit 
of  the  nerve.  This  should  be  followed  or  accompanied  by  hot 
fomentations.  Salicylate  of  soda  in  full  doses  of  twenty  grains 
should  be  given  during  the  first  week.  After  the  paralysis  is  es- 
tablished, iodide  of  potassium  is  indicated  in  moderate  doses. 
Electricity  is  to  be  employed  with  care  at  first.  After  a  week  it 
may  be  given  daily  for  five  minutes,  using  the  galvanic  currents 
just  strong  enough  to  contract  the  muscles.  After  three  or  four 
weeks,  if  the  faradic  current  causes  contraction,  it  may  be  used, 
otherwise  the  galvanic  current  is  to  be  continued.  At  the  end  of 
a  month  an  application  every  other  day  is  sufficient.  At  the  end 
of  three  weeks,  if  the  paralysis  is  severe,  the  corner  of  the  mouth 
should  be  drawn  up  by  means  of  a  bent  hook,  which  is  carried 
back  and  fastened  behind  tlie  ear.  The  patient  should  wear  this 
most  of  the  day-time,  but  not  at  night.  The  object  is  to  take 
off  the  strain  caused  by  the  pulling  of  the  muscles  on  the  sound 
side. 

At  the  end  of  a  couple  of  months,  if  secondary  contractures 


138  DISEASES   OF   THE   NERVOUS   SYSTEM. 

set  in  massage  may  be  tried,  and  the  patient  should  ijractise 
facial  gymnastics  daily. 

Acupuncture  combined  with  weak  faradic  currents  and  local 
injections  of  strychnia  maybe  tried  in  obstinate  cases. 

If  the  eye  cannot  be  closed  it  should  be  protected  by  a  shade. 

DISEASES  OF  THE  EIGHTH  ^sERVE. 

The  diseases  of  the  eighth  or  acoustic  and  space-sense  nerve 
which  are  of  especial  interest  to  the  neurologist  are  auditory 
paralysis  or  nervous  deafness,  hyperacusis,  tinnitus  aurium,  and 
auditory  vertigo  or  Meniere's  disease.  These  diseases  correspond 
with  loss,  excess,  and  perversion  or  irritation  of  function. 

IXeryous  Deafness  (Acoustic  Paralysis). 

Nervous  deafness  may  be  due  to  lesions  (1)  of  the  cortical  centres 
of  hearing,  (2)  of  the  acoustic  nuclei,  and  (3)  of  the  acoustic  nerve 
itself  or  its  end-organ.  Practically  it  is  almost  always  the  nerve 
and  the  internal  ear  which  are  affected. 

Etiology. — 1.  Cortical  nervous  deafness  has  been  known  to 
occur  in  a  few  instances  from  lesions  of  both  temporal  lobes 
(Mills).  A  lesion  in  the  left  temporal  lobe  causes  a  form  of  sen- 
sory aphasia  called  word  deafness.  A  lesion  in  the  right  temporal 
lobe  may  cause  some  deafness  in  the  left  ear.  The  deafness  of 
hysteria  is  of  cortical  orgin. 

2.  Deafness  from  lesion  of  the  acoustic  nucleus  or  nerve  root. 

Cerebro-spinal  meningitis  in  the  young  and  syphilitic  menin- 
gitis in  the  adult  are  the  more  frequent  causes  of  this  form. 
Tumors  and  hemorrhages  may  also  be  causes.  When  the  audi- 
tory nucleus  and  nerve  root  are  affected  by  these  diseases,  its 
peripheral  terminations  in  the  labyrinth  are  also  often  involved, 
so  that  sharp  distinctions  cannot  always  be  drawn  between  this 
form  and  that  due  to  labyrinthine  disease. 

8.  Deafness  from  Labyrinthine  Disease. — The  causes  are 
drugs,  such  as  quinine  and  the  salicylates;  inflammations,  includ- 
ing syphilitic  exudates,  injuries,  hemorrhages,  tumors,  primary 
atroiDhy  which  may  occur  in  locomotor  ataxia ;  mechanical  causes, 
such  as  the  constant  noises  and  jarring  to  which  locomotive  en- 
gineers and  boiler-makers  are  subject. 

Symptoms  of  Ner^cous  Deafness.— The  dominant  symptom  is 
loss  of  hearing,  but  this  may  be  accompanied  with  vertigo,  tin- 
nitus, and  even  forced  movements.' 

In  hysterical  deafness  the  loss  of  hearing  is  rarely  complete,  is 
unilateral,  and  especially  involves  high  and  low  notes.  Deafness 
from  involvement  of  the  nucleus  and  nerve  root  is  usually  accom- 


DISEASES   OF   THE   CRANIAL  NERVES.  139 

panied  with  other  symptoms  of  a  basilar  meningitis  or  lesion  of 
the  pons  and  medulla.  Labyrinthine  deafness  is  often  associated 
with  vertigo,  tinnitus,  and  forced  movements,  when  it  may  be- 
come a  symptom-complex  known  as  "  Meniere's  disease." 

Sudden  total  deafness  is  characteristic  of  syphilitic  disease  of 
the  internal  ear.  In  genuine  nervous  deafness,  unless  the  deaf- 
ness is  absolute,  bone  conduction  is  lost,  while  aerial  conduction 
is  preserved.  A  tuning-fork  vibrating  on  the  skull  or  mastoid  is 
not  heard  by  the  affected  ear,  though  it  is  heard  when  held  in 
the  air  close  by  this  ear.  Changes  of  reaction  to  the  electrical 
current  occur,  but  the  tests  are  difficult  and  the  results  unsatis- 
factory. 

The  treatment  depends  upon  the  seat  and  nature  of  the  lesion. 
In  labyrinthine  deafness  it  is  generally  limited  to  the  use  of 
iodide  of  potassium,  mercury,  pilocarpine,  leeches,  and  the  gal- 
vanic current.  Local  applications  and  surgical  interference  may 
be  required.  The  treatment  of  nervous  deafness  in  which  ver- 
tigo, forced  movements,  and  tinnitu.s  are  the  dominant  symp- 
toms will  be  discussed  under  these  heads, 

TixxiTus  AuRiuM,  Ti]?fxiTus  Cerebri  (Xoises  in  the  Ear 
AND  Head). 

Subjective  sounds  resembling  hissing,  buzzing,  humming, 
beating,  musical  notes,  etc.,  are  classed  together  under  the  gen- 
eral head  of  tinnitus  aurium.     It  is  a  very  common  symptom. 

Etiokxji/. — The  disease  attacks  adults  in  middle  and  later  life. 
Men  and  women  are  alike  affected.  Neuropathic  constitutions 
and  an  unstable  circulation  favor  it.  The  arterio-sclerosis  of  old 
age,  cerebral  anaemia  and  congestion,  sunstroke,  tobacco,  and 
alcoholism  lead  to  it.  It  occurs  often  in  melancholia  and  in  neu- 
rasthenia. Some  local  disease  or  congestion  of  the  middle  or  in- 
ternal ear  is  usually  present.  Tinnitus  occurs  in  Bright's  disease, 
gout,  and  dyspepsia. 

Disease  of  the  auditory  nuclei  and  auditory  tracts  rarely,  if 
ever,  causes  tinnitus;  but  chronic  pachy-meningitis,  such  as  fol- 
io avs  blows  on  the  head,  sunstroke,  alcoholism,  etc.,  may  be  at- 
tended with  most  annoying  tinnitus,  which  is  often  not  so  much 
in  the  ears  as  in  the  head— a  tinnitus  cerebri.  In  old  people  with 
thickened  arteries  and  imperfect  brain  nutrition  a  similar  condi- 
tion may  occur. 

Tinnitus  accompanies  insanity  sometimes,  and  may  be  the 
source  of  aural  hallucinations. 

A  kind  of  tinnitus  may  accompany  migraine  and  take  the 
form  of  an  aura  in  epilepsy. 

Despite  this  long  list  of  causes,    the  chief   factors  may  be 


140  DISEASES   OF  THE   NERVOUS   SYSTEM. 

summed  up  as  neurasthenic  states,  local  ear  disease,  humoral 
poisons  and  irritants,  reflex  irritants,  arterio-sclerosis. 

The  symptoms  are  indicated  by  the  name  of  the  malady. 
They  may  come  on  suddenly,  but  usually  develop  slowly.  Some 
deafness  and  occasional  vertigo  are  often  present.  The  noise  is 
located  in  one  ear  as  a  rule.  Sometimes  it  is  said  to  be  simply 
"  in  the  head."  The  sounds  are  generally  present  all  the  time, 
giving  the  patient  little  rest  and  making  life  a  burden.  They 
vary  greatly  in  character  and  intensity.  These  variations  are 
indicated  in  the  study  of  the  diagnosis. 

The  Diagnosis. — The  recognition  of  the  symptom  is  easy.  The 
principal  thing  is  to  discover  its  seat  and  cause. 

The  ear  should  of  course  be  examined  for  external  or  middle 
€ar  disease. 

If  the  tinnitus  is  pulsating  and  synchronous  with  the  heart- 
beats and  stopped  by  carotid  compression,  it  may  be  inferred 
that  it  is  due  to  vasomotor  paralysis,  or  inflammatory  conges- 
tion, or  aneurism. 

If  the  sound  is  not  in  the  ear,  but  in  the  head,  and  not  asso- 
ciated with  deafness  or  ear  disease,  the  trouble  is  probably  cen- 
tral, and  most  likely  is  of  meningeal  or  arterio-sclerotic  origin. 

Noises  which  are  complex  or  take  the  form  of  musical  sounds 
or  words  are  probably  central. 

Constant  rushing,  knocking,  jDulsating  noises  are  due  to  con- 
gestion, hemorrhage,  or  inflammatory  effusion  in  the  labyrinth. 

Moist  sounds  of  a  gurgling,  bubbling,  boiling,  singing,  whis- 
tling, shell-like  roaring  character  indicate  disease  of  the  middle 
ear,  with  fluid  exudation  or  catarrh  of  the  Eustachian  tube,  or 
irritation  of  the  external  auditory  canal,  mastoid  cells,  or  post- 
nasal spaces. 

Dry  roaring  and  ringing  noises  are  due  to  non-suppurative 
catarrh  of  middle  ear,  disease  of  the  muscles  or  nervous  supjoly 
of  the  tympanum,  meningitis,  tumors,  and  syphilis. 

The  condition  of  the  digestion  should  be  inquired  into  and 
the  existence  of  renal,  arterial,  or  of  central  nervous  disease  inves- 
tigated. 

Treatment. — Hydrobromic  acid  and  the  other  bromides  are 
the  surest  remedies  for  this  trouble,  given  in  ordinary  doses. 
They  may  be  combined  with  digitalis.  Iodide  of  potassium  and 
iodide  of  ethyl  often  are  useful.  Nitroglycerin  is  sometimes  of 
value  in  patients  with  hard  arteries.  A  combination  of  digitalis, 
bromide,  and  nitroglycerin  has  given  me  the  best  results.  Occa- 
sionally tonics  are  indicated.  I  have  seen  but  little  good  from 
electricity,  or  counter-irritation.  Of  course  middle-ear  disease 
must  be  treated  if  it  is  present. 


DISEASES   OF   THE   CRANIAL   NERVES.  141 


Vertigo  (Dizziness,  Giddiness). 

Vertigo  is  a  disturbance  of  consciousness  characterized  by  ap- 
parent movements  of  external  objects  or  of  the  person  himself. 
If  external  objects  whirl  around,  the  vertigo  is  called  ohjectice; 
if  the  person  himself  seems  to  move,  it  is  called  subjective.  Ver- 
tigo is  almost  always  a  symptom.  In  rare  cases  it  appears  to 
be  idiopathic. 

Vertigo  is  connected  more  or  less  with  our  space  sensations, 
and  hence  it  will  be  described  here  under  disorders  of  the  eighth 
cranial  nerve  and  its  central  representations. 

Etiology.— T\\e  causes  of  vertigo  may  be  classed  somewhat 
like  those  of  headache,  as  follows : 

1,  Hsemic:  anaemia,  hypersemia,  toxaemia,  from  tobacco  and 
alcohol;  2,  arterio-sclerosis ;  3,  acoustic-nerve  irritation;  4,  neu- 
roses :  epilepsy,  neurasthenia ;  5,  reflex :  ocular,  gastric ;  G,  organic 
brain  disease ;  7,  mechanical  causes  like  electricity,  swinging, 
etc. 

Based  mainly  on  the  etiology,  we  have  as  a  practical  classifica- 
tion of  ordinary  cases  of  vertigo:  toxic,  auditory,  gastric  and 
bilious,  ocular,  neurasthenic,  and  epileptic  forms.  The  various 
causes  of  vertigo  act  partly  by  irritating  the  space-sense  nerve 
and  thus  disturbing  our  sense  of  relation  to  external  objects, 
partly  by  irritating  the  cortical  centres  of  the  brain. 

SymiAoms. — Vertigo  comes  on  suddenly,  and  lasts,  as  a  rule, 
for  but  a  moment.  The  floor  rises  up  and  sinks  down,  or  objects 
whirl  around  (objective  vertigo),  or  the  patient  seems  whirling 
around  or  falling.  The  ideas  are  confused,  there  is  a  sense  of 
alarm  and  a  feeling  of  faintness.  The  patient  totters,  sometimes 
falls ;  there  may  be  nausea  or  vomiting.  In  some  forms  there  is 
momentary  loss  of  consciousnses,  or  syncope.  Vertigo  usually 
comes  on  in  short  attacks,  but  in  toxsemic  states  as  in  alcoholism 
or  nicotinism  it  is  almost  constant  while  the  poison  is  in  the  sys- 
tem. 

Vertigo  may  become  chronic  or  nearly  so;  and  if  severe  it 
forms  what  is  called  the  status  vertiginosus  (Mitchell).  Vertigo 
is  increased  by  rising  or  sudden  movements  and  lessened  by  lying 
down. 

Vertigo  due  to  organic  lesions  of  the  cerebellum  and  its 
peduncles,  or  of  the  labyrinth,  is  associated  with  forced  movements 
of  the  body. 

Sijmptoms  of  Special  Forms.— Auditory  Vertigo  {Meniere's 
Disease).— K  large  proportion  of  vertigoes  are  due  to  disease  or  irri- 
tation of  the  eighth  nerve  and  its  centres.  The  common  cause 
is  local  disease  of  the  labyrinth.     When  this  produces  severe  at- 


142  DISEASES   OF   THE   NERVOJJS   SYSTEM. 

tacks  of  vertigo  with  nausea  and  iDerhaps  syncope,  it  is  called 
"Meniere's  disease."  The  name  is  often  applied  to  any  form  of 
auditory  vertigo.  Meniere's  type  is  always  due  to  organic  disease 
of  the  labyrinth.  It  is  accompanied  with  progressive  deafness, 
and  sometimes  with  tinnitus  and  forced  movements,  or  even  an 
utter  inability  to  walk  steadily.  When  the  deafness  is  complete 
the  vertigo  ceases,  because  the  nerve  end-organ  is  destroyed. 
Mild  forms  of  auditory  vertigo  present  nothing  unusual  except 
those  due  to  involvement  of  the  nerve  of  hearing. 

Man 5^  forms  of  vertigo,  such  as  the  gastric  and  toxic,  occur 
through  a  reflex  disturbance  of  the  eighth  nerve.  The  auditory 
nuclei  are  connected  with  those  of  the  vagi.  The  labyrinth  is 
supplied  with  blood  by  the  vertebral  artery,  whose  calibre  is  con- 
trolled by  symiDathetic  fibres  which  are  in  close  connection  with 
fibres  to  the  stomach.  Hence  reflex  effects  may  occur  through 
contiguity  of  the  central  nuclei  and  by  reflex  spasm  of  the  vessels 
of  the  internal  ear.  "  Stomachal  vertigo"'  is  the  name  given  to 
a  very  severe  form  of  reflex  vertigo.  It  occurs  generally  in 
l^ersons  whose  stomachs  are  overloaded  and  digestion  paralyzed 
by  its  load.     It  is  accompanied  by  loss  of  consciousness. 

Bilious  and  Lithcemic  Vertigo. — In  conditions  of  dyspepsia, 
constipation,  and  hepatic  torpor,  the  disordered  stomach  and 
bowel  suddenly  discharge  into  the  blood  irritant  substances 
which  pass  to  the  brain  and  by  direct  action  on  the  nervous  cen- 
tres cause  vertigo.  This  is  probably  the  explanation  of  the  ver- 
tigo of  biliousness  and  constipation.  It  is  a  paroxysmal  vertigo, 
noted  most  in  the  morning,  not  very  severe,  and  often  accom- 
panied Avith  nausea. 

Neurotic  Vertigo. — The  symptoms  of  epileptic  vertigo  will  be 
described  under  that  head. 

Neurasthenic  vertigo  is  a  not  uncommon  sjauptom.  The  at- 
tacks are  short,  generally  subjective,  not  severe  or  accompanied 
with  nausea  or  syncope,  but  they  often  cause  much  alarm.  Un- 
derlying them  are  exhausted  and  irritable  nerve  centres,  with 
ocular,  gastric,  and  humoral  irritations. 

A  neurotic  vertigo  occurs  sometimes  in  the  form  of  attacks 
almost  exactly  resembling  seasickness.  There  is  intense  vertigo, 
nausea,  and  faintness  lasting  for  hoiirs,  coming  on  suddenly  with- 
out known  cause  except  overwork  or  excitement.  The  attacks 
occur  in  neurotic  subjects  and  are  analogous  to  other  nervous 
crises.     It  is  a  periodical  neurosis  of  the  space-sense  nerve. 

In  some  nervous  subjects  there  occurs  a  sudden  giving  way  of 
the  legs.  There  is  no  conscious  vertigo,  yet  such  probably 
exists.  The  symptom  is  noted  in  exophthalmic  goitre.  It  is  a 
"  stumbling  vertigo." 

Ocular  t'e^'^/^o  is  a  rare  symptom,  but  is,  when  present,  chronic 


DISEASES   OF   THE   CRANIAL   NERVES.  143 

and  annoying?.  It  is  caused  by  refractive  errors  and  unequal 
action  of  the  ocular  muscles. 

The  mechanical  vertigoes  are  such  as  are  produced  by  swinging, 
whirling,  the  movements  of  the  ship,  steam-car,  and  elevators. 
Railway  mail-clerks,  elevator  boys,  often  suffer  from  chronic  dis- 
turbances of  a  vertiginous  character.  Ocular  and  auditory  nerve 
sensations  enter  into  the  causation. 

After io-sclerotic  Vert/go,  Senile  Vertigo. — This  occurs  in  per- 
sons who  have  arterio-sclerotic  changes  in  the  l^rain-vessels,  either 
from  disease  or  senility.  The  symptom  is  caused  by  imi^aired 
brain  nutrition  with  consequent  ansemia.  Senile  vertigo  may 
also  be  due  to  a  weak  and  fatty  heart. 

Pathology. — The  consciousness  of  the  proper  equilibrium  of 
the  body  and  of  its  relations  to  the  external  world  depends  upon 
the  continuous  inflow  of  nervous  impulses  from  the  eye  and  its 
muscles,  from  the  nerves  of  the  muscles,  joints,  and  viscera,  and 
from  the  ear.  Anything  M^hich  suddenly  disorders  this  even  in- 
flow may  cause  a  disturbance  of  consciousness  and  sensations  of 
vertigo. 

The  aural  impulses  come  from  the  semi-circular  canals  and 
ampullae ;  they  are  the  most  important.  These  impulses  are  not 
felt  in  consciousness  normally,  but  go  to  certain  lower  centres 
chiefly  in  the  vermis  of  the  cerebellum.  From  this  point  they 
influence  the  acts  concerned  in  holding  the  body  in  equilibrium. 

When  impulses  from  the  eye  and  its  adjusting  mechanism  do 
not  flow  in  normally,  there  may  be  disturbance  of  consciousness 
and  a  feeling  of  vertigo.  Probably  visceral  impulses  can  produce 
a  similar  disturbance.  Everything  which  suddenly  interferes 
with  the  nutrition  of  the  cortex  of  the  brain,  such  as  anaemia  and 
poisons,  may  lead  to  giddiness  by  lowering  the  level  of  conscious- 
ness and  confusing  the  sensory  inflow. 

Diagnosis. — In  investigating  vertigo  the  physician  should  find 
(1)  whether  it  is  subjective  or  objective,  (2)  loaroxysmal  or  chronic, 
(3)  accompanied  w^ith  ear  symptoms,  nausea,  tinnitus,  and  loss  of 
consciousness.  He  should  then  direct  himself  to  finding  the  spe- 
cial cause  and  seat,  remembering  that  the  auditory,  gastric,  toxic, 
and  neurasthenic  are  the  common  forms.  In  elderly  persons  the 
arteries  should  be  carefully  examined.  In  young  persons  the 
possibility  of  epilepsy  must  be  remembered. 

The  prognosis  depends  upon  the  cause.  Epileptic  vertigo  and 
vertigo  from  organic  disease  are  most  serious.  Labyrinthine 
vertigo  usually  ceases  Avhen  complete  deafness  occurs.  The  other 
forms  of  vertigo  are  usually  susceptible  of  relief. 

Treatment.— The  attack  is  treated  by  rest  in  the  horizontal 
position  and  the  administration  of  a  volatile  stinmlant.  The 
disorder  must  then  be  treated  in  accordance  with  the  cause. 


144-  DISEASES   OF   THE   NERVOUS   SYSTEM. 

In  Meniere's  vertigo  the  use  of  quinine  by  Charcot's  method 
is  said  to  be  useful.  Quinine  is  given  in  doses  which  are  gradually 
increased  until  cinchonism  results.  Then  the  drug  is  stopj^ed. 
Mitchell  advises  the  addition  of  hydrobromic  acid;  Gowers  ad- 
vises the  use  of  salicylate  of  soda  in  five-grain  doses  instead 
of  quinine.  Hirt  recommends  ten  drops  of  a  two-per-cent 
solution  of  pilocarpine  injected  hypodermically  every  other 
day. 

Neurasthenic  vertigo  is  cured  by  rest  and  attention  to  diet, 
laxatives  and  mineral  acids  being  used.  Hydrobromic  acid  with 
pepsin  and  glycerin  are  often  very  helpful  here.  Gastric  vertigo 
is  to  be  treated  with  saline  laxatives  and  simple  bitters  before 
meals. 

In  the  vertigo  of  "  biliousness  *"  and  litluemia  there  is  often  a 
neurasthenic  element,  and  a  similar  attention  to  diet  and  to  the 
digestive  organs  is  indicated.  In  arterio-sclerotic  and  senile  ver- 
tigo small  doses  of  nitroglycerin  and  iodide  of  potassium,  with 
or  without  digitalis,  should  be  given.  Rest  and  warmth  of  the  ex- 
tremities are  indicated.  In  all  forms  of  vertigo  bromide  of  potas- 
sium is  helpful  and  will  relieve  the  symptoms  for  a  time.  It  is 
the  best  symptomatic  remedy.  Counter-irritation  to  the  neck  or 
mastoid  region  by  the  cautery  does  good  occasionally. 

There  are  two  peculiar  forms  of  disease  to  which  the  name 
vertigo  has  been  attached  which  may  be  described  here. 

Laryngeal  Syncope  (Laryngeal  Vertigo,  L.  Epilepsy). 
— This  is  a  rare  form  of  disorder  characterized  by  attacks  of 
paresthesia  of  the  throat,  with  coughing,  followed  by  sudden  syn- 
cope, and  sometimes  by  slight  convulsive  movements. 

The  disease  occurs  chiefly  in  males  at  about  the  age  of  fifty, 
though  the  range  of  age  is  thirty-five  to  seventy.  Neurotic  con- 
stitution is  often  present.  There  may  be  a  history  of  injury  and 
the  use  of  stimulants.  Laryngitis,  bronchitis,  apical  phthisis,  and 
asthma  may  be  present. 

At  the  onset  of  the  attacks  a  burning  or  tickling  sensation  is 
felt  in  the  larynx  or  trachea;  there  is  a  spasmodic  cough,  per- 
haps some  asthmatic  or  dyspncjeic  symptoms,  when  the  patient 
suddenly  falls,  unconscious  for  a  short  time.  The  attacks  may 
occur  daily  or  only  once  in  a  few  weeks.  Most  cases  are  curable, 
yet  the  disease  is  not  without  danger. 

It  is  probably  a  reflex  neurosis,  not  a  true  epilej^sy. 

The  treatment  should  be  directed  to  the  relieving  any  local 
condition  or  pulmonary  trouble.  Bromide  of  potassium  should 
also  be  given. 

Paralyzing  Vertigo  (Gerlier's  Disease).— This  is  a  dis- 
ease occurring  only  on  the  farms  in  southern  France  and  Switzer- 
land. 

The  symptoms  consist  of  sudden  attacks  of  ptosis,  vertigo, 
paresis  of  arms  and  legs,  and  cervico-occipital  pain.  The  disease 
is  most  prevalent  in  the  summer-time.  It  attacks  chiefly  males. 
Single  attacks  last  not  over  ten  minutes,  but  may  occur  fre- 
quently. 


DISEASES   OF  THE   CRANIAL  NERVES. 


145 


The  cause  is  supposed  to  be  a  special  microbe  developed  in 
the  stables  during  the  heat  of  summer. 

We  are  not  aware  of  its  occurrence  in  America,  though  Seguin 
calls  attention  to  the  close  similarity  of  the  symptoms  to  those 
of  poisoning  by  conium  maculatum. 

Hyperacusis  (Auditory  HYPERiESTHESiA).— When  there  is 
undue  keenness  of  the  sense  of  hearing,  the  condition  is  called 
hyperacusis.  It  occui-s  in  hysteria  and  hypnotic  states.  Some 
persons  have  naturally  an  extraordinary  keenness  of  hearing.  In 
facial  paralysis  there  is  sometimes  hyperacusis  due  to  paralysis  of 
the  stapedius. 

When  ordinary  sounds  cause  painful  feelings,  the  condition  is 
called  dysacusis.  This  occurs  in  the  neurasthenic  and  hysterical, 
in  persons  of  enfeebled  vitality,  in  the  brain  congestion  of  fevers, 
and  in  meningitis ;  also  in  local  ear  troubles  of  an  inflammatory 
character. 


Fig.  67.— Case  for  Testing  Sense  of  Taste  and  Smell. 
lO 


146 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Diseases  of  the  Glosso-Phartngeal  Nerve. 

Tlie  motor  fibres  are  affected  with  spasm  causing  dysphagia 
and  a  feehng  called  globus;  they  are  also  affected  by  paralysis 
in  the  disease  called  glosso-labio-laryngeal  palsy. 

The  sensory  fibres  are 
affected  also  in  globus. 
The  special  sense  of 
Taste  is  affected,  causing 
ageusia  or  loss  of  taste. 

Of  these  diseases  no 
one  belongs  to  the  glos- 
so-pharyngeal  nerve 
alone.  It  will  be  con- 
venient, however,  to  de- 
scribe disorders  of  taste 
here. 

Ageusia  (loss  of 
the  sexse  of  taste) 
is  an  affection  in  which 
the  power  to  discrimi- 
nate the  tastes  of  bit- 
ter, sweet,  salt,  acid,  and 
alkaline  substances  is 
lost. 

Etiology. — It  occurs 
oftenest  in  an  incom- 
plete form  in  facial 
palsy  and  in  hysteria. 
SHOWING  THE  Re-    Injurlcs  of  the  trigem- 


Fig.  68.— Modified  from  Erb, 

LATIOXS  OF  THE   SEVENTH  AND    GlOSSO-PhARYNGEAL      iUUS  aud  glOSSO-pliarj'U 


Nerves  and  the  Course  of  the  Taste  Fibres.  The 
lines  1,  2,  3,  4,  and  5  mark  off  different  segments  of 
the  nerve;  AVm  facial  nerve;  i\'.a.,  acoustic  nerve; 
G.ph.,  glosso-pharyngeal  nerve;  G.g.,  geniculate 
ganglion;  A'.p.-s.,  great  superficial  pelvosal  from 
fifth  nerve;  N.c.cxy.t..  tj-mpanic  plexus;  the  dotted 
line  Sxjs.  indicates  salivary  fibres;  the  other  dotted 
line  indicates  taste  fibres;  Ch.t.,  chorda  tympani' 
N.St.,  stapedius  nerve;  F.st.,  sty lo-mastoid foramen. 


geal  nerves,  catarrhal 
diseases  of  the  mucous 
membrane  of  the  mouth 
and  nose,  are  frequent 
causes.  It  is  not  caused 
by  organic  brain  disease 
so  far  as  known. 

Si/mptoms.  —  Some 
ageusia  is  present  in  the  imbecile,  and  the  sense  of  taste  is  less 
keen  in  the  lowly  organized  and  criminal  classes. 

The  symptoms  are  subjective  and  may  not  be  noticed  at  first 
by  the  patient.  In  hemiageusia  from  facial  palsy  and  hysteria  it 
has  to  be  looked  for,  as  the  patient  does  not  complain.  The  tests 
are  made  with  solutions  of  salt,  sugar,  vinegar,  and  quinine.     A 


DISEASES   OF   THE   CRANIAL  NERVES.  147 

sin^rle  solution  of  su^ar  usually  answers.  But  the  different  parts 
of  tiie  tongue  differ  m  aensibility  to  different  substances  (Fig.  07). 

Care  must  be  taken  to  exclude  the  nose  as  a  factor  in  taste. 

Pathol oyi/.—Agenaisi  occurs  as  the  result  of  disease  of  the  roots 
of  the  trigeminus,  especially  of  the  second,  also  from  disease  of 
the  facial  when  the  chorda  tymi^ani  is  implicated  and  from  dis- 
ease of  the  glosso-pharyngeal  root. 

Disease  of  the  trigeminus  and  facial  usually  causes  ageusia  on 
the  anterior  two-thirds  of  the  tongue,  with  loss  of  taste,  espe- 
cially for  sour  and  bitter  substances.  Sometimes,  however,  dis- 
ease of  the  trigeminus  or  disease  of  the  tympanum  involving  the 
tymi:)anic  plexus  and  chorda  tympani  causes  ageusia  of  the  whole 
tongue  on  the  affected  side. 

Ageusia  from  disease  of  the  glosso-pharyngeal  alone  is  very 
rare,  and  then  causes  loss  of  taste  on  the  posterior  third  of  the 
tongue,  soft  j^alate  and  pillars  of  the  fauces,  with  loss  of  taste 
to  sweets  and  acids.  A  few  cases  have  been  reported  in  which 
paralysis  of  the  glosso-pharyngeal  caused  complete  ageusia  on 
the  affected  side.  It  must  be  inferred,  therefore,  that  taste  fibres 
run  sometimes  wholly  in  the  fifth,  more  rarely  wholly  in  the 
ninth  nerves,  and  usually  in  both. 

The  treatment  depends  on  the  cause.  Locally,  cleansing  and 
stimulating  mouth-washes  and  electricity  may  be  used. 

Parageusia  or  perversions  and  imperfections  in  the  taste 
sense  are  very  frequent.  They  are  generally  due  to  irritation  of 
the  taste  nerves  from  catarrhal  inflammation  of  the  stomach  or 
mouth.     They  also  occur  in  hysteria. 

Diseases  of  the  Pxeumo-gastric  Nerye  aj^d  of  the 
Bulbar  Portion  of  the  Spixal  Accessory. 

These  nerves  are  essentially  visceral  in  character.  Their  dis- 
eases call  for  a  study  of  laryngeal,  pulmonary,  cardiac,  and  abdom- 
inal neuroses,  which  would  bring  us  into  the  domain  of  laryngol- 
ogy and  general  medicine.  Hence,  despite  their  great  importance, 
1  have  thought  it  best  not  to  try  and  present  them  here.  Some 
of  the  symjotoms  are  described  in  connection  with  locomotor 
ataxia,  progressive  muscular  atrophy,  exophthalmic  goitre,  and 
angina  pectoris. 

Diseases  of  the  Hypoglossal  Nerye. 

The  diseases  of  this  nerve  consist  of  lingual  spasms,  lingual 
palsy,  and  lingual  hemiatrophy. 

Lingual  spasms  take  part  in  the  disorders  of  articulation, 
helping  to  cause  stuttering  and  speech  cramps.     Such  troubles  are 


148  DISEASES   OF   THE   NERVOUS   SYSTEM. 

often  developmental  in  origin  and  belong  to  the  habit- choreas 
or  convulsive  tics. 

Stuttering  is  a  spasmodic  disorder  in  which  the  tongue  mus- 
cles are  involved,  preventing  the  proper  enunciation  of  words  and 
sentences. 

Stammering  is  an  imjDerfect  articulation  due  sometimes  to 
disease  or  defect  in  the  hypoglossal  nerve  and  its  muscles.  It  is 
not  a  spasm. 

Aphtho7igia  is  the  name  given  to  a  form  of  spasm  occurring  in 
speakers  and  similar  in  nature  to  writers  cramp. 

Clonic  lingual  spasm  occurs  in  chorea,  hysteria,  and  during 
the  attacks  of  epilepsy.  Unique  cases  of  this  si^asm  also  occur 
from  reflex  irritation  or  central  nervous  disease. 

Tonic  lingual  spasm  occurs  in  hysteria,  and  sometimes  as  an 
independent  affection  due  to  unknown  causes,  generally  those  of 
a  debilitating  and  nervously  depressing  character.  Reflex  irrita- 
tion may  be  a  cause. 

LiXGUAii  PARALYSIS  (glossoplegia)  is  usually  one  of  the 
symptoms  of  glosso-labio-laryngeal  palsy.  It  may  be  caused  by 
a  bilateral  lesion  in  the  cerebral  hemispheres.  The  condition  is 
then  known  as  pseudo-bulbar  paralysis.  Diseases  of  the  medulla 
and  of  the  nerve  itself  may  cause  the  paralysis. 

The  paralysis  may  be  either  unilateral  or  bilateral.  The 
symptoms  are  an  impairment  of  speech  and  of  swallowing.  Fuller 
details  will  be  given  under  the  head  of  Bulbar  Palsy. 

Progressive  Lingual  Hemiatrophy. — A  progressive  hemiatro- 
phy of  the  tongue  sometimes  occurs.  It  is  analogous  in  all  re- 
spects to  facial  hemiatrophy,  with  which  it  is  sometimes  associ- 
ated. It  is  iDrobably  due  to  a  low^  grade  of  degenerative  neuritis 
of  the  nerve.     It  is  very  rare. 

DISEASES  OF  THE  SPINAL  PART  OF  THE  ACCESSORIUS. 

This  is  a  purely  motor  nerve,  and  its  disorders  are  therefore 
spasm  and  paralysis. 

Torticollis  (Wry-Neck,  Caput  Obstipum). 

Torticollis  is  a  disease  characterized  by  clonic  or  tonic  spasm 
of  the  muscles  supplied  by  the  spinal  accessory  and  often  of  other 
muscles  of  the  neck.  There  are  several  forms  of  w^ry-neck,  which 
must  be  distinguished  from  each  other.  They  are:  1,  congenital 
wry-neck ;  2,  symptomatic  wry-neck ;  3,  spurious  wry-neck,  from 
spinal  disease;  4,  true  spasmodic 'wry-neck. 

1.  Congenital  wry-neck  is  due  to  some  intra-uterine  atrophy 
or  obstetrical  injury  of  the  sterno-cleido- mastoid.  It  occurs 
oftenest  after  breech  or  foot  presentations.     The  right  side  is 


I 


DISEASES   OF   THE   CRANIAL  NERVES. 


149 


usually  affected.  There  is  no  spasin  at  all,  but  the  neck  is  fixed 
to  one  side  by  the  shortness  of  the  muscle,  and  also  rotated  to  the 
opposite  side.  The  deformity  becomes  more  noticeable  as  the 
child  grows  older,  because  the  parts  atrophy.  The  atrophy 
affects  not  only  the  shortened  muscles,  but  the  face  on  the  af- 
fected side. 

2.  Symptomatic  wry-neck  is  usually  due  to  a  rheumatic  myo- 
sitis, and  occurs  chiefly  in  children.  It  may  be  due  also  to  tumors, 
adenitis,  abscesses,  and  local  syphilitic  disease.  In  these  cases 
there  is  always  pain  and  tenderness  associated  with  the  deformity. 

8.  iSpurious  lory-neck  is  an  apparent  or  real  spasm  of  the  neck 
muscles  due  to  caries  of  the 
spine. 

Treatment. — C  ongenital 
wry-neck,  if  taken  early,  can 
be  cured  by  tenotomy  of  the 
sterno-mastoid  and  s  u  b  s  e  - 
quent  fixation  of  the  neck 
for  a  time.  AVhen  osseous 
changes  have  occurred  per- 
fect relief  is  impossible.  Symp- 
tomatic rheumatic  wry-neck 
is  a  trivial  and  temporary  af- 
fection, which  needs  only  to 
be  palliated  by  hot  applica- 
tions and  saline  purges  until 
cure  takes  place. 

Spurious    wry-neck    re- 
quires suitable  orthopedic  measures,  such  as  the  plaster  jacket 
and  jury-mast. 

4.  ^Spasmodic  Wry-Week. — This  is  a  purely  nervous  disease 
characterized  by  spasm  of  the  muscles  supplied  by  the  spinal 
accessory  and  sometimes  by  the  upper  cervical  nerves. 

Etiology.— MV omen  are  much  oftener  affected  than  men.  It 
occurs  in  early  adult  and  middle  life,  never  in  children  or  old 
people.     A  neuropathic  constitution  and  heredity  often  exist. 

The  exciting  causes  are  occupations  which  put  the  lateral 
muscles  of  the  neck  on  a  strain,  depressing  emotions,  physical 
shocks  and  blows,  rheumatic  Influences,  and  perhaps  malaria. 
Sometimes  no  cause  can  be  detected.  Reflex  irritations,  perhaps, 
exist  in  some  cases,  but  it  is  difficult  to  find  them. 

/Symptoms.— The  disease  begins  with  slightly  painful  sensa- 
tions in  the  neck,  which  are  soon  accompanied  with  spasm.  The 
spasm  is  at  first  clonic  and  intermittent.  The  sterno-mastoid  is 
oftenest  involved  of  single  muscles;  but  the  rule  is  that  the 
upper  fibres  of  the  trapezius  are  also  affected.     The  patient's 


Fig. 


-Wry-Neck  of  Right  Side. 


150 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


head  is  inclined  toward  the  affected  side  by  the  trapezius,  the 
chin  is  raised  and  the  head  rotated  to  the  opposite  side  by  the 
sterno-mastoid  and  trapezius,  and  this  is  the  typical  position  in 
the  disease.  If  both  trapezii  are  affected  the  head  is  pulled  back, 
but  this  is  a  rare  form.  It  is  called  retrocollic  spasm.  The  com- 
plexus  and  obliquus  superior  are  the  only  other  neck  muscles 
which  can  rotate  the  head  to  the  opposite  side.  They  are  sup- 
plied by  the  upper  cervical  nerves  and  are  sometimes  involved 
in  wry-neck.  In  torticollis  the  muscles  affected  with  spasm  have 
a  similar  physiological  function.  Hence  while  the  sterno-mas- 
toid, trapezius,  complexus,  and  superior  oblique  on  one  side  are 
attacked  by  the  spasms,  muscles  on  the  other  side  may  be  at  the 
same  time  implicated.  The  opposite  muscle  commonly  affected 
is  the  splenius,  which  inclines  the  head  laterally  and  rotates  it  to 
the  same  side.  Probably  the  deep  muscles,  recti  capitis  postici, 
major  and  minor,  and  the  inferior  oblique,  wdiich  draw  the  head 
back  and  rotate  to  the  same  side,  are  also  at  times  affected.  The 
list  of  muscles  that  may  be  involved  and  their  nerve  supply  is  as 
follows : 

Function. 


Turning  Head  fo  Opposite 
Side. 


Muscles  usually  '■  Sterno-eleido-mastoid  . . . 
involved.  •  Upper  fibres  of  trapezius. 


Muscles     rarely     Superior  obliquus. 
involved.  Complexus 


Turning  or  Inclining  Head 
to  Same  Side. 


Nerve 
Supplj'. 


Eleventh. 
Eleventh. 


Recti  capitis   postici,    maj.,     Cei'vical. 
min.,  inter,  obliq.,  splenius.     Cervical. 


Extreme  rotation  without  much  retraction  of  the  head  would 
indicate  involvement  of  the  sterno-cleido-mastoid  and  opposite 
splenius.  Retraction  of  the  head  indicates  involvement  of  both 
trapezii. 

The  disease  may  start  in  one  muscle  and  gradually  extend  to 
others,  even  involving  the  facial,  masticatory,  and  brachial  nerves. 
As  it  progresses  the  spasm  becomes  more  constant,  and  finally  it 
may  be  tonic,  never  yielding  except  to  artificial  means  or  during 
sleep.  The  pain  associated  with  the  disease  gradually  decreases. 
The  affected  muscles  hypertrophy,  the  muscles  thrown  into  dis- 
use atrophy.  There  is  some  deformity,  in  time,  of  the  neck  and 
shoulders,  but  facial  asymmetry  does  not  occur  in  this  form 
unless  it  begins,  as  is  very  rarely  the  case,  before  maturity. 

The  disease  may  be  complicated  with  or  alternate  with  other 
neuroses.     I  have  known  epilepsy  to  be  associated  with  it. 

Pathology. — The  disease  is  a  neurosis  involving  the  bulbar  and 
lower  cerebral  centres.  The  neuro-mechanism  controlling  the 
movements  of  the  neck  is  unstable  and  out  of  control.     Conse- 


DISEASES   OF   THE   CRANIAL   NERVES.  151 

quently  it  sends  out  intermittent  and  irregular  discharges  of 
nerve  force.  The  seat  of  the  typical  disease  is  never  in  the  nerve 
alone,  probably  not  in  the  cortex. 

It  is  a  disturbance  of  nutrition  and  function;  it  has  no  patho- 
logical anatomy,  though  vascular  disturbances  of  the  nerves  and 
centres  may  be  present. 

The  diagnosis  has  to  be  made  from  the  other  forms  of  wry- 
neck mentioned.  The  age,  history,  and  fixed  character  of  the 
spasm  serve  to  distinguish  congenital  wry-neck.  The  history, 
the  pain  and  tenderness,  and  the  temporary  duration  differen- 
tiate the  rheumatic  forms. 

The  increased  rigidity  on  passive  motion,  the  pain,  deformity, 
and  other  signs  of  cervical  caries  are  sufficient  to  diagnosticate 
vertebral  disease. 

Prognosis. — The  disease  is  not  fatal.  It  generally  reaches  a 
certain  stage  and  then  remains  chronic.  In  rare  cases  it  is 
cured ;  in  many  others  it  can  be  much  ameliorated.  Cases  occur- 
ring in  young  people,  in  the  hysterical,  and  in  those  without  a 
decided  neurotic  history  are  the  most  favorable. 

Treatment.— The  drugs  Avhich  are  efficient  are  opium,  atropia 
or  hyoscyamine,  conium,  gelsemium,  valerianate  of  zinc,  asa- 
f  oetida,  chloral,  bromides,  arsenic,  and  cocaine.  Of  these,  opium, 
atropia,  gelsemium,  and  zinc  are  generally  the  most  efficacious. 
Opium  must  be  given  with  great  caution.  Atropia  should  be 
given  hypodermically  in  increasing  doses  up  to  intoxication  (gr. 
3^0)  (Leszynsky).  The  galvanic  and  faradic  currents  are  useful 
adjuvants  in  helping  to  relax  the  spasm  and  keep  up  the  nutri- 
tion of  the  muscles;  but  alone  they  are  not  curative.  Massage 
and  stretching  the  neck  in  a  Sayre  apparatus,  together  with 
systematic  exercise  of  the  neck  muscles,  often  help ;  neck-stretch- 
ing will  even  sometimes  cure.  The  only  surgical  measures  to  be 
advised  are  nerve-resection,  and  possibly  the  partial  cutting  of 
the  sterno-mastoid  muscle.  A  very  few  cures  and  many  failures 
have  followed  surgical  interference. 

Splints  and  mechanical  fixation  apparatus  do  no  good  as  a 
rule. 

Resection  of  the  posterior  branches  of  the  upper  three  or  four 
cervical  nerves  as  suggested  by  Keen  has  done  great  good  in  a 
few  cases  (Powers). 

Spasmus  Nutans  (eclampsia  nutans,  nodding  spasm,  salaam 
spasm,  oscillating  spasm). — This  is  a  disorder  occurring  chiefly  in 
children  and  characterized  by  rhythmical  nodding  or  oscillat- 
ing movements  of  the  head. 

Etiology. — The  disease  occurs  in  young  children  who  are  anae- 
mic and  badly  nourished.  Dentition,  digestive  disorders,  basilar 
meningitis,  gross  disease  of  the  brain,  are  causes.     Sometimes  it  is 


152  DISEASES    OF   THE    NERVOUS   SYSTEM. 

only  a  kind  of  habit  chorea,  and  occasionally  tliis  habit  contin- 
ues during  life. 

Si/ m2)tom.s.  — The  disease  may  come  on  suddenly ;  more  rarely 
it  develops  slowly.  The  patient  has  paroxysms  usually  of  a 
rather  Ariolent  character,  lasting  for  minutes  or  houi"^,  or  even 
continuing  neai'ly  aH  the  time  ^except  during  sleep.  The  head 
moves  thfrty  to  sixty  times  a  minute  usually,  but  the  motion 
may  be  slower  or  faster.  Movements  of  the  eyes  and  taeial  mus- 
cles often  complicate  the  atfeetion.  The  paroxysm  may  end  in  an 
epileptic  attack. 

The  diai/nosi-y  is  easily  made  by  the  symptoms.  The  prognosis 
and  treatmt/it  depend  upon  the  etiology.  Bromide  of  potassium, 
hyoscine.  and  syrup  of  iodide  of  iron  1  have  found  useful. 

Paralysis  of  the  Spinal  Part  of  the  Accessory.— Zr/- 
ology. — The  causes  are  injuries,  caries  of  vertebra,  progressive 
muscular  atrophy,  and  all  forms  ot  si:)inal  disease  reaching  high 
up  in  the  cervical  cord. 

Symptoms. — When  one  nerve  is  paralyzed  the  head  may  still 
be  held  straight,  but  there  is  inabiliTv  to  rutare  it  perfectly.  The 
prominence  of  the  sterno-mastoid  is  absent— atrophy  takes  place. 
^N'o  spasm  of  the  other  muscle  oceui*^.  and  there  is  no  such  thing 
as  paralytic  torticollis  (^Gowers  .  The  involvt-ment  of  the  trape- 
zius causes  a  depression  in  the  cuntour  of  the  neck,  especially 
noticeable  on  deep  inspiration.  There  is  some  trouble  in  raising 
the  arm,  the  scapula  is  drawn  away  from  the  spine,  and  the 
lower  angle  is  rotated  inward.  AThen  both  nerves  are  paralyzed 
there  is  great  difficulty  in  rotating  the  head  or  raising  the  chin. 
Paralysis  of  both  sterno-mastoids  causes  the  chin  to  drop  back- 
ward, while  paralysis  of  both  trapezii  in  theii'  upper  parts  causes 
the  head  to  drop  forward.  Atrophy  of  the  muscles  attends  the 
paralysis  of  the  nerve,  and  degenerative  reactions  may  be  noted. 
The  cervical  nerves  appear  sometimes  to  supply  the  sterno-ma-- 
toid  and  ui^per  part  of  the  trapezius  so  much  that  in  disease  ^.i 
the  accessories  de<?ided  jjaralyric  symptoms  are  absent.  "When 
both  parts  of  the  spinal  accessory  are  involved,  dropping  of  the 
palate,  dysphonia,  and  rapid  pulse  are  added  symptoms. 

The  diagnosis  depends  upon  a  thorough  examination  of  tl 
motility  of  the  parts. 

The  treatmtnt  is  based  un  a  knowledge  of  the  cau-e  oi  tlie 
disease. 


CHAPTER  IX. 

DISEASES   OF   THE   SPINAL  NERVES. 


Anatomy  and  Physiology. — The  spinal  nerves  arise  from  the 
spinal  cord  by  two  roots,  anterior  and  posterior.  These  roots 
unite  outside  the  spinal  canal  to  form  mixed  nerves.  The  mixed 
nerves  divide  and  go  to  their  various  destinations.  There  are 
thirty-three  pair  of  spinal  nerves,  viz. : 


Cervical, 

Dorsal, 

Lumbar, 

Sacral, 

Coccygeal, 


(all  rudimentary) 


The  last  two  coccygeal  nerves  are  microscopic  in  size,  and  the 
first  pair  is  very  small,  so  that  practically  there  are  but  thirty 
sets  of  spinal  nerves. 

The  posterior  roots  are  connected  with  ganglia  lying  in  the 
intervertebral  canal,  and  called  intervertebral  ganglia,  or  ganglia 
of  the  posterior  roots.  The  mixed  nerve  is  connected,  by  fibres 
that  come  chiefly  from  the  anterior  root,  with  the  sympathetic 
or  prevertebral  ganglia. 

For  the  purpose  of  conveniently  studying  the  diseases  of  the 
syjinal  nerves.  Ave  divide  them  into  six  different  groups,  each  having 
a  somewhat  definite  work  to  do.  These  groups  are  shown  in  the 
accompanying  table,  also  on  p.  82. 


Group    I . . 
••      II.., 


III. 
IV. 


V... 

VI.., 


Strands  of  Spinal 
Nerves. 


Upper  four  cervical. 
Lower  four  cervical 
and  first  dorsal. 

Upper  six  dorsal. 

Lower  six  dorsal  ex- 
cept last. 

Twelfth  dorsal,  four 
lumbar. 

Fifth  lumbar  and  five 
sacral. 


Distribution. 


Occipital  region,  neck. 
Upper  extremities. 


Thoracic  wall. 

Abdominal  wall,  upper 
lumbar,  upper  lateral 
thigh  surface. 

Lumbar  region,  iipper 
gluteal,  anterior  and  in- 
ner thigh  and  knee. 

Lower  gluteal,  posterior 
thigh,  leg.  ^ 


Associated  Ganglia 
of  Sympathetic. 


First  cervical. 
Second   and  third 
cervical,  first  dor- 
sal. 
First  to  sixth  dor- 
Fifth     to    twelfth 
dorsal. 

First  to  fourth  lum- 
bar. 

First    to   fifth  sa- 
cral. 


Group  I.  The  Upper  Cervical 

includes  the  first  four  of  the  spinal  nerves.  These  divide  into  an- 
terior and  posterior  branches.  The  posterior  branches  supply  the 
muscles  and  skin  of  the  back  of  the  neck  and  the  occiput.     The 


15-i 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


principal  nerves  are  the  suboccipital  and  great  occipital.  The  an- 
terior branches  form  the  cervical  plexus.  Its  principal  branches 
are  the  auricularis  magnus,  occipitalis  minor,  and  phrenic.     The 


Fig.  70.— The  Spinal  Nerves,  showing  their  groupings  and  plexuses  (after  Baker). 

special  distribution  of  the  nerves  is  shown  in  the  table  and  Fig. 
71. 

The  upper  cervical  nerves  supply  motion  to  the  muscles  which 
rotate  the  head  and  draw  it  back  and  sideways. 

One  branch,  the  phrenic,  supplies  the  diaphragm;  other  mus- 


DISEASES   OF   THE   SPINAL  NERVES.  155 

cles  assist  in  fixing:  the  thorax  in  forced  inspiration.  They  inner- 
vate some  of  the  hyoid  and  thyroid  muscles,  but  have  no  influ- 
ence on  phonation  or  degUitition.  This  <<roup  of  nerves  is  in  close 
connection  centrally  with  the  trigeminal  nerve,  whose  descending 
root  reaches  down  into  the  cervical  cord.  The  fibres  to  the  scalp 
and  face  also  anastomose  with  the  trigeminus  in  their  perii^heral 
distribution  to  the  scalp  and  chin. 

The  diseases  of  the  upper  cervical  group  are  spasms,  paralyses, 
and  neuralgias. 

Spasmodic  Diseases.— Torticollis  may  be  limited  to  the 
cervical  nerves,  as  has  been  shown. 

Tonic  spasm  causing  a  rigid  neck  is  a  frequent  symptom  of 
meningitis,  and  forms  x^art  of  epileptic  and  other  convulsions. 

In  oscillatory  and  rotatory  si)asms  the  cervical  nerves  are  in- 
volved. 

Hiccough  is  a  clonic  spasmodic  disorder  of  the  phrenic  nerve. 
It  is  usually  due  to  gastric  disturbance,  with  flatulent  distention 
of  the  stomach. 

When  chronic,  it  is  caused  by  hysteria,  neuritis,  diaphragmatic 
pleurisy,  or  some  pressure  upon  the  nerve  in  its  course.  1  have 
seen  a  case  in  Avhich  it  was  probably  a  pure  spasmodic  neurosis. 
Ordinarily,  hiccough  can  be  stopped  by  simple  carminatives  like 
spirits  of  chloroform  or  lavender.  In  obstinate  cases  in  which  no 
known  cause  can  be  found,  jjilocarpine,  hyoscine,  and  bromides 
are  useful.  Counter-irritation  along  the  neck  helps  some  cases. 
A  most  effective  measure  is  to  lay  the  patient  supine  over  a 
thick  bolster  so  that  the  head  hangs  down  and  the  thorax  arches 
up. 

Paralyses  axd  Atrophy.— The  cervical  nmscles  are  para- 
lyzed in  progressive  muscular  atrophy  and  in  pachy-meningitis 
hypertrophica,  and  occasionally  in  vertebral  and  peripheral  dis- 
ease or  injury.  Some  deformities  and  weakness  in  head  move- 
ments result,  but  the  most  serious  consequence  is  involvement 
of  respiration  through  palsy  of  the  i:)hrenic. 

Paralysis  of  the  Phrenic  2serye.— ^^z'oZo^/?/.— Such  pa- 
ralysis may  be  due  to  disease  or  injury  of  the  cervical  cord,  and 
also  to  peripheral  disease,  to  which  the  nerve  is  somewhat  liable 
owing  to  its  long  course  through  the  anterior  mediastinum. 

Pleurisy,  peritonitis,  mediastinal  tumors,  rheumatic  and  toxic 
influences,  and  hysteria  are  among  the  special  causes  of  phrenic 
paralysis.  Spinal-cord  disease  is,  however,  the  commonest  eti- 
ological factor. 

Symptoms.— \n  diaphragmatic  paralysis,  if  bilateral,  as  is  usu- 
ally the  case,  there  is  either  no  movement  of  the  abdomen  or  the 
epigastrium  and  hypochondrium  are  drawn  in.  On  slight  exer- 
tion there  is  dyspnoea  and  increase  of  respiration. 


156 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Diagnosis.— If  no  other  muscles  than  the  diaphragm  are  in- 
volved,' the  cause  is  probably  in  the  trunk  of  the  nerve.  Inflam- 
matory disease  of  the  diaphragm  may  cause  a  paralysis  which  is 
recognized  by  its  painful  character  and  the  febrile  reaction. 

Treatment— This  is  to  be  guided  by  the  cause.  It  need  only 
be  said  here  that  there  is  a  motor  point  in  the  neck  where  by 


Fig.  71.— Showing  :  (1;  The  relation  of  the  spinal  nerve  roots  to  the  spinous  pro- 
cesses; (2)  the  arrangement  of  the  brachial  plexus;  (3)  the  level  of  origin  and  (4) 
the  distribution  of  the  chief  motor  and  sensory  nerves  of  the  arm.  Small  letters 
refer  to  sensory  distribution,  figures  to  mixed  nei-ves;  capital  letters  represent  the 
nerve  roots  from  which  the  nerves  are  derived,  a,  Great  occipital;  b,  small  occipital; 
c.  clavicular;  d.  circumflex;  e,  i)osterior  dorsal;  /,  musculo-spiral ;  g.  lateral  dorsal; 
h,  external  cutaneous;  i,  internal  cutaneous;  j,  musculo-cutaneous;  k,  radial;  I, 
ulnar;  vi.  median. 


1.  Suprascapular. 
(From  5  and  G  C.) 


2.  Subscapular. 
(From  5  and  6  C.) 


4.  Musculo-cutaneous.     j  Biceps. 
(From  4  and  5  C.  roots. ^  I  Brac-liialis  ant 
Flex.  carp,  ulnar. 


3  and  6.  Musculo-spiral. 
(From  4,  5,  6,  7,  8  C. 
i-oots.) 


5.  Ulnar. 
(From  8  C.  and  1  D.) 


One-half  tlex.  prof. 

dig.  interossei. 
One-half   lumbri- 

cales. 
One-half  flex.  poUic. 
Add.  pollicis. 


7.  Median, 
(From  0, 


'  Supinators. 
Ext.  carp.  rad. 

and  ulnar. 
Ext.  com.  dig. 
Ext.  pollicis. 
Triceps     and 
anconeus. 
C  Pronators. 
1  Flex.  carp.  rad. 
I  Flex.  subl.  dig. 
-I  One-half  flex. prof. dig. 


8  C.)  I  Abd.  oppon.  and  one- 
I      half  flexor  pollicis. 
i  One-half  lumbricales. 


DISEASES   OF   THE   SPINAL   NERVES 


157 


careful  electrization  one  can  ^et  a  contraction  of  the  diaphragm. 
In  paralysis  this  fact  should  be  utilized. 

Cervico-Occipital  Neuralgia— Neck  Vm^ss.— Etiology.^ 
Pains  in  the  back  of  the  head  and  neck  occur  in  migraine,  in 
hysteria,  spinal  irritation,  and  neurasthenia,  as  a  result  of  eye 
strain,  as  a  true  neuralgia,  and 


as  a  symptom  of  brain  tumor, 
meningitis,  and  rheumatic  in- 
flammation of  the  neck  mus- 
cles and  nerves.  True  cervico- 
occipital  neuralgia  is  not  rare, 
is  much  more  common  in 
women,  occurs  between  the 
ages  of  twenty  and  thirty-five, 
and  is  often  a  reflex  of  pelvic 
disease. 

Symptoms.  —  Migrainous 
pains  have  been  described.  In 
si:)inal  irritation  and  hysteria 
the  trouble  is  central,  or  per- 
haps shifting;  it  is  especially 
characterized  by  a  sharp  boring- 
pain  just  below  the  occiput. 
With  it  there  may  be  evidences 
of  cerebral  congestion  or  anae- 
mia, with  vertigo  and  faintness, 
but  not  vomiting.  The  boring 
pain  is  almost  pathognomonic 
of  spinal  irritation.  In  neuras- 
thenia the  pain  is  more  of  a 
tired,  aching  character.  In 
typical  neuralgia  the  jjain  is 
usually  unilateral,  paroxysmal, 
and  sharp,  sometimes  reaching 
the  intensity  of  a  tic  doulou- 
reux. There  are  tender  points 
over  the  exit  of  the  nerves. 
The  disease  lasts  for  five  or  six 
weeks.  If  of  reflex  origin,  it 
may  become  chronic.  The 
pains  may  alternate  with  or 
take  the  place  of  a  trigeminal 
neuralgia.  The  nerves  involved 
are  the  great  and  small  occipital 
from  the  second  pair  and  a 
branch  from  the  third  pair. 


LI 


J2 


8 


JO 


^ 


J]Ccrv 
I] 

3 
3 
3 


ical 


Dovral 


3 


3 


// 


io\ 


m 


'[[Lumha/* 

D 

Fig.  72.— Showing  the  Relation  of  the 
Spinous  Puocess  to  the  Roots  op  Ori- 
gin OF  THE  Spinal  Nerves.  The  small 
squares  to  the  right  indicate  the  spinous 
processes;  the  large  spaces  indicate  the 
nerve  roots  and  the  variation  vertically  in 
their  origin.  The  relation  of  nerve  root  to 
spine,  therefore,  varies  considerably  (Reid). 


158  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Treatment.— Generfii  constitutional  treatment  consists  in  the 
use  of  anti-rheuuiatics,  such  as  the  sahcylates.  The  muriate  of 
ammonia  has  done  me  good  servcie.  In  women  pelvic  troubles 
should  be  looked  for :  in  both  sexes  the  eyes  must  be  attended  to. 
Locally,  counter-irritants,  cupping,  and  leeching  are  useful;  mus- 
tard and  capsicum  pastes  are  often  a  great  relief.  The  ice-bag 
also  is  of  service.  Trephining  the  occipital  bone  has  cured  one 
obstinate  case,  and  resecting  the  occipital  nerves  another. 


Group  II.  The  Lower  Cervical  ]S'erves  and  Brachial 

Plexus. 

Anatomy  and  Physiology. — The  anterior  branches  of  the  lower 
four  cervical  nerves  and  first  dorsal  nerve  unite  to  form  the 
brachial  plexus.  This  gives  off  short  nerves  to  the  shoulder  and 
trunk  and  long  nerves  to  the  arm. 

The  mode  of  formation  of  the  brachial  plexus  is  shown  in  the 
diagram  (Fig.  78).  It  is  in  accordance  with  the  descriptions  of 
Walsh  and  Allen.  The  short  or  ui:)per  branches  supply  the 
shoulder  and  intercostal  muscles.  The  long  or  lower  branches 
sujjply  the  arm  and  hand.  The  neurologist  needs  to  know-  (1) 
tlie  muscular  distribution  of  each  nerve  and  the  function  of  the 
muscle;  (2)  the  cutaneous  sensory  distribution;  and  (8)  the  level 
of  origin  of  the  nerves. 

The  accompanying  figures  and  table  give  these  points,  and  will 
be  found  useful  for  study  and  reference.  They  are  based  upon 
the  investigations  of  Ferrier  and  Yeo,  Thorburn,  and  also  on 
Abbe's  and  my  own  experiments. 

The  Arrangement  of  the  Brachial  Plexus. — It  is  made  up  of 
three  nerve  trunks,  which  in  turn  make  up  three  cords,  these. 
cords  giving  off  various  branches,  thus : 

1.  Trunk  from  sixth  )  •,.„,_,  ^,,x,  „  ^^   .    (  Ext.  ant.  thoracic. 

and  s  e  V  e  n  t  h     ^^5  "'.  ''*tL^  o^'  \  Musculo-cutaneous. 
cervical  roots    \    ^'^^^^^^  ^^^^^  ^^    (  Outer  head  median. 

f  Inner  head  median. 

2.  Trunk  from  eighth  1  ,  .  -.1  Ulnar. 

cervical  and^first  ^Thth^^vl '''';?'     Int.  cutan. 
dorsal  roots  j     ^^  hich  gives  off     j  jnt.  ant.  tliorac. 

l^  Intercost.-hum. 

3.  Trunk  from  lifth,1  C ^   ,  , 

sixth,  seventh,  (  forms  posterior  cord,  J  ^^^^^^^^J^''" 
and  eighth cer V.  r       which  gives  off     M  Ciicumttex. 
and  first  dorsal  J  ^Musculo-spu-al. 

The  following  table  shows  the  origin,  muscular  distribution, 
and  effect  of  paralysis  on  the  motor  but  not  on  the  sensory 
nerves.     This  latter  is  indicated  in  the 'figure  (Fig.  71); 


DISEASES   OF   THE   SPINAL   NERVES 


159 


Nerves  and  Roots  of 
Origin. 


IMuseular 
Distribution. 


Function  as  Shown  by  Effect  of 
Paralysis. 


Posterior  thoracic. 
Fifth  and  sixth  cervical. 


Circumflex. 

Fifth,  sixth,  seventh,  and 

eig-hth  cervical. 
Suprascapular. 


Subscapular,  short. 
Fifth  and  sixth  cervical. 

Subscapular,  long. 

Fifth,  sixth,  seventh,  and 

eighth  cervical. 
Anterior  thoracic. 

Musculo-cutaneous. 
Fourth  and  fifth  cervical. 
Musculo-spiral. 
Fourth,   fifth,   sixth,   sev- 
enth, and  eighth  cervical. 


Median. 

Fifth,  sixth,  seventh,  and 
eighth  cervical. 


Ulnar. 

Eighth  cervieal,first  dorsal. 


Serratus  majrnus. 


Deltoid. 
Teres  minor. 

Supraspinatus. 


Infraspinatus    and 

teres  minor. 
Subscapulares. 
Teres  major. 

Latiss.  dorsi. 


Pectoralis  major. 

Biceps   and  bra,chi- 

alis  anticus. 
Triceps 
Supinatores. 

Extensor  carp.  rad. 
Extensor  carp.  uln. 

Extensor    c  o  m  m  . 

digit. 
Extensor  p.  i.  polllc. 
Extensor  s.  i.  pollic. 
Extensor  o  s  s.  met. 

pollic. 
Pronatores. 
Flexor  carp.  rad. 
Flexor  sublim.  dig. 
Flexor  prof  und.  dig. 

radial  half. 
Two  lumbricales. 
Abductor  pollic. 
Flexor  pollic. 
Flexor  carp,  ulnar. 

Flexor  profund.  dig. 
ulnar  half. 

Interossei. 
Two  lumbricales. 
Flexor  minor  digit. 
Adductor  pollicis. 
Inner  half  of  flexor 
brev.  pollicis. 


Posterior  edge  of  scapula  is  rotat- 
ed out  when  arm  is  raised  and 
carried  forward. 

Weakening  of  elevation  of  shoul- 
der and  of  inspiration. 

Loss  of  power  to  raise  arm. 


Weakened  power  to  raise  arm  ; 
head  of  humerus  tends  to  fall. 

Loss  of  abductors,  motion  forward 
and  inward  rotation  of  humerus. 

Loss  of  rotation  of  humerus  out- 
ward. 

Weakens  inward  rotation  of  arm. 

Weakens  power  of  elevating 
shoulder. 

Weakens  power  to  depress  shoul- 
der and  to  pull  arm  backward 
and  to  side. 

Loss  to  pull  arm  down  and  for- 
ward and  to  shrug  the  shoulder. 

Loss  of  flexion  of  forearm  and 
weakness  of  inspiration. 

Loss  of  extension  of  forearm. 

Loss  of  sui^inatiou. 

Extension  of  wrist  lost  except 
when  fingers  are  flexed  ;  lateral 
deviation. 

Impaired  extension  of  first  pha- 
langes and  wrist. 

Impairment  of  extension  of  thumb. 


Loss  of  pronation. 

Weakened  flexion  of  wrist. 

Weakened  flexion  of  second  and 
third  phalanges  of  first  and  sec- 
ond fingers. 

Loss  of  abduction  and  flexion  of 

thumb. 
Weakened  flexion  of  wrist;  radial 

deviation. 
Weakened  flexion  of  second  and 

third    phalanges   of   third  and 

fourth  fingers. 
Loss  of  flexion  of  first  phalanges 

and  of  extension  of  second  and 

third. 


DiSEA.SES    OF    THE     LOW^ER   CERVICAL    NeRVE    CtROUP     AND 

THE  Brachial  Plexus.— The  nerves  of  this  group  are  sub- 
ject to  the  pathological  disturbances  couinion  to  all  nerves.  I 
shall  describe  them  from  the  clinical  side,  which  gives  the  follow- 
ing disorder.^; 

f  Combined  arm  palsies. 
-p       ,  I  Upper-arm  type  or  Erb's  palsy. 

j  Lower-arm  type. 

i.  Paralysis  of  individual  nerves. 


160  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Spasmodic  Disorders,  i  Occupation  neuroses. 

/  Brachial  neuralgia. 
Sensory  Disorders.       -  Digital  neuralgia. 

( ]N"umb-hands. 

Secretory,      Trophic,  r 
and    Vasomotor-^  Neurotic  cedema. 
Disorders.  ' 

Brachial  Paralyses,  Arm  Palsies.— These  occur  as  com- 
bined or  total  arm  palsies,  upper-arm  and  lower-arm  types,  and 
paralyses  of  single  nerves. 

Combined  paralysis  of  the  brachial  nerves  is  a  condition  in 
which  all  or  nearly  all  the  branches  of  the  plexus  and  its  branches 
are  involved.  Total  arm  palsies  make  up  about  six  per  cent  of 
all  peripheral  paralyses,  and  are  about  one-fifth  as  frequent  as 
single-nerve  paralyses. 

Etiology. — They  occur  oftenest  in  men,  but  are  not  rare  in  in- 
fants, being  then  due  to  injuries  during  parturition.  After  in- 
fancy they  are  most  frequent  in  early  and  middle  life. 

The  exciting  causes  are  obstetrical  and  other  injuries;  deep- 
seated  inflammations  and  tumors;  shoulder  dislocations;  pri- 
mary neuritis;  crutch  and  other  forms  of  mechanical  compres- 
sion; functional  palsies,  from  overwork  and  hysteria;  in  rare 
cases,  spinal-cord  and  brain  disease. 

The  symptoms  vary  with  the  severity  and  extent  of  the  lesion. 

With  regard  to  severity,  there  are  three  degrees.  In  the  first 
there  is  simply  a  transient  palsy,  due  to  lying  too  long  on  the 
arm.  The  arm  feels  heavy,  numb,  and  "  asleep."  In  a  few  min- 
utes or  hours  this  palsy  disappears.  In  the  second  degree  the 
nerves  are  so  much  compressed  as  to  be  mechanically  injured. 
If  the  patient  has  been  drinking  hard,  even  moderate  pressure 
may  set  up  an  inflammatory  or  destructive  process  that  leads  to 
quite  a  serious  palsy.  In  the  third  degree  the  nerves  are  actually 
cut  or  torn  across,  or  so  compressed  as  to  lose  their  anatomical 
integrity. 

The  resulting  symptoms  are  those  common  to  all  nerve  in- 
juries, viz.,  paralysis,  wasting,  changes  in  electrical  reaction  of 
the  muscles.  Pain,  tenderness,  anaesthesia,  trophic,  secretory, 
and  vasomotor  disturbances  are  also  present  in  varying  degree. 

The  distribution  of  the  paralysis,  atrophy,  and  sensory  dis- 
turbance depends,  of  course,  upon,  the  arm  nerves  chiefly  in- 
volved. The  diagram  (Fig.  71)  will  enable  one  to  see  in  any  case 
where  the  trouble  is  localized. 

There  are  three  common  symptoms,  however,  of  which  it  is 
often  very  important  to  analyze  the  cause.     These  are  the  loss  of 


DISEASES   OF   THE   SPINAL  NERVES.  161 

power  for  elevation  of  the  arm  and  for  flexion  and  extension  of 
the  forearm. 

Flexion  of  the  forearm  is  performed  by  the  biceps  and  braehi- 
alis  anticus,  and  is  helped  by  the  supinator  lon^us.  These  mus- 
cles are  supplied  by  the  musculo-cutaneous  nerve,  except  the 
supinator,  which  is  supplied  by  the  musculo-spiral.  Hence  when 
a  person  cannot  flex  the  forearm,  the  musculo-cutaneous  is  chiefly 
affected. 

Extension  of  the  arm  is  done  by  the  triceps,  which  is  supplied 
by  the  musculo-spiral. 

Elevation  of  the  Arm  Outward. — Inability  to  raise  the  arm  is 
the  common  and  striking  symptom  in  combined  brachial  palsies. 
The  arm  is  raised  by  a  number  of  muscles.  The  deltoid  acts  first 
and  most,  but  it  can  only  raise  the  arm  to  a  right  angle.  It  is 
supplied  by  the  circumflex  nerve  from  the  posterior  cord  of  the 
plexus.  After  the  arm  is  raised  to  a  right  angle,  it  is  further 
elevated  by  rotating  the  scapula,  and  this  is  done  chiefly  by  the 
middle  part  of  the  trapezius  (lower  cervical  and  upper  dorsal 
nerves)  and  by  the  serratus  magnus,  supplied  by  the  posterior 
thoracic  nerve.  A  number  of  other  muscles  combine  to  strengthen 
elevation  of  the  shoulder,  but  this  action  can  only  be  abolished 
by  paralysis  of  the  deltoid  or  trapezius  and  serratus  magnus. 

The  diagnosis  of  these  cases  involves,  first,  the  consideration 
of  the  seat  of  the  lesion  and  the  special  nerves  involved ;  next,  that 
of  the  nature  of  the  lesion,  A  recognition  of  the  seat  of  the 
lesion  and  of  the  special  nerves  involved  depends  entirely  upon 
the  study  of  the  distribution  of  the  palsy  and  of  the  atrophy  and 
sensory  disturbance.  It  is  important  to  determine  whether  one 
is  dealing  with  a  total  arm  palsy,  an  upper-arm  type  (Erb's  palsy), 
or  a  lower-arm  type. 

In  ErVs  palsy  there  is  involvement  of  the  deltoid,  biceps, 
brachialis  anticus,  and  supinator  longus,  with  at  times  i^aralysis 
of  the  supinator  brevis,  and  even  of  all  the  muscles  supi^lied  by 
the  median  nerve.  The  lesion  is  either  in  the  cord  formed  by  the 
fifth  and  sixth  cervical  nerves  or  a  little  lower  in  the  brachial 
plexus,  where  the  fibres  supplying  the  musculo-spiral,  circumflex, 
and  musculo-cutaneous  lie  close  together.  At  all  events,  the 
lesion  involves  the  central  parts  and  upper  cords  of  the  plexus. 
The  arm  hangs  by  the  side  and  the  forearm  cannot  be  flexed. 

In  the  loioer-arm  type  the  triceps,  the  flexors  of  the  wrist,  the 
pronators,  the  flexors  and  extensors  of  the  fingers,  and  the  hand 
muscles  are  involved.  The  arm  can  be  raised  and  the  forearm 
flexed  and  supinated,  but  the  hand  is  useless  and  the  extension 
of  the  forearm  is  impossible.  The  lesion  here  involves  chiefly 
the  nerves  from  the  seventh  and  eighth  cervical  and  first  dorsal 
roots. 

II 


162 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


If  the  lesion  is  in  the  nerve  there  will  be  atrophy,  changes  in 
electrical  reaction,  sensory  disturbances,  and  often,  if  there  is 
neuritis,  pain  over  the  nerves.  The  reflexes  will  be  lessened  or 
absent.  If  the  lesion  is  in  the  spinal  cord,  symptoms  in  other 
parts  of  the  body  will  be  present,  or,  if  not,  there  will  be  no  sen- 
sory disturbance,  as  in  an  arm  palsy  from  anterior  poliomyelitis. 
In  rare  cases  arm  palsies  may  be  caused  by  spinal  tumors  or  a 
local  meningitis,  in  which  case  diagnosis  is  dithcult. 

The  prognosis  is  usually  good.  Nearly  all  these  cases  get  well, 
the  duration  of  the  incapacity  being  from  two  or  three  months  to 
a  year.  Even  in  the  severest  cases  recovery  is  possible  after  one  or 
two  vears.     If,  however,  the  nerves  are  torn  across  and  the  ends 


AR«   or  /kNAESTHEIlA 


Fig.  73.— Illustrating  the  Formation  op  the  Brachial  Plexus;  also  the 
Involvement  op  the  Plexus  in  Degenerative  Neuritis  (Le:>zynsky). 


widely  separated,  recovery  is  doubtful  unless  an  operation  is 
promptly  done. 

The  treatment  consists  in  electrical  applications,  mechanical 
support,  with  potassium  iodide  internally  and  abstinence  from 
alcohol.  Local  injections  of  nitrate  of  strychnine  are  useful,  and 
massage  should  be  used  if  it  can  be  applied  carefully. 

In  brachial  palsies  due  to  severe  injuries,  dislocations,  frac- 
tures, etc.,  in  which  there  is  evidence,  from  the  extreme  atrophy 
and  absence  of  electrical  reaction,  that  the  nerve  is  entirely  cut 
across  and  that  the  ends  are  not  in  apposition,  a  surgical  opera- 
tion is  stringently  needed.  The  nerves  should  be  exposed  and 
the  ends  brought  as  near  together  as  possible.  Decalcified  bone- 
tubes  or  sterilized  macaroni  may  be  used  to  give  a  passage  for  the 
central  end  to  grow  into  the  peripheral.  In  these  cases,  however, 
it  must  be  remembered  that  the  two  ends  do  not  unite :  but  the 


DISEASES   OF   THE   SPINAL  NERVES.  163 

central  end  grows  down  into  the  tract  of  the  old  degenerated 
peripheral  stem. 

The  upper -arm  type  and  loioer-ann  type  palsies  are  caused  l^y 
much  the  same  factors  as  the  combined  palsies ;  their  symptoms 
have  been  indicated  above.  The  upper-arm  type  is  especiaUy 
frequent  in  infants  and  constitutes  one  of  the  obstetrical  paral- 
yses. It  may  in  some  cases  be  due  to  injury  or  hemorrhage  in 
the  cord. 

A  peculiar  form  of  combined  nerve  pals}^  sometimes  occurs, 
due  apparently  to  d^  primary  hrachial  neuritis.  It  begins  in  the 
plexus  and  involves  first  the  nerves  of  the  ux^per  cervical  roots. 
It  may  extend  down  and  involve  the  ulnar,  median,  or  musculo- 
spiral. 

It  occurs  in  adult  men  generally  and  in  those  exposed  to  rheu- 
matic influences.     Perhaps  lead-poisoning  may  exist. 

It  begins  gradually  with  slight  pains  and  weakness  in  the 
shoulder  and  arm  muscles.  Atrophy  and  anaesthesia  follow,  and 
degeneration  reactions  are  present.  There  is  not  a  great  deal  of 
pain  (Fig.  73).  The  disease  is  usually  confined  to  one  side.  It 
lasts  several  months,  and  nearly  complete  recovery  finally  takes 
place.     Relapses  may  occur. 

It  is  differentiated  from  progressive  muscular  atrophy  by  the 
pain,  anicsthesia,  and  electrical  reactions  and  from  arthritic 
atroi^hy,  by  the  absence  of  any  history  of  arthritis  and  the  pres- 
ence of  degeneration  reactions  and  anaesthetic  areas. 

Paralyses  of  Sixgle  Nerves.— Paralysis  of  the  Pos- 
terior Thoracic  Xerve.— j£'^/oZo(/^.— This  rare  trouble  usu- 
ally occurs  in  male  adults  and  is  due  to  injury  or  sudden  strains. 
Its  paralysis  may  be  part  of  a  progressive  muscular  atrophy. 
The  nerve  goes  to  the  serratus  magnus. 

iSymjjtoms.— When  paralyzed,  there  is  difficulty  in  raising  the 
arm  above  the  horizontal  position  and  the  movements  of  the 
shoulder  are  weakened.  AVhen  the  arm  hangs  by  the  side  the 
lower  angle  of  the  scapula  is  drawn  a  little  nearer  the  vertebral 
column  and  protrudes  slightly.  When  the  arm  is  held  out  hori- 
zontally the  inner  edge  of  the  scapula  protrudes  and  is  drawn 
toward  the  middle  line.  When  the  raised  arm  is  brought  for- 
ward there  is  a  deep  groove  formed  between  the  inner  border  of 
the  scapula  and  the  thoracic  wall. 

The  disease  often  runs  a  long  course  and  is  accompanied  with 
pain. 

Paralysis  of  the  Circumflex  Xerve.— The  nerve  goes  to 
the  deltoid,  teres  minor,  third  head  of  the  triceps,  and  yhoulder 
joint.  It  gives  sensation  to  the  skin  of  the  shoulder.  It  is  very 
often  paralyzed.  The  commonest  cause  is  a  fall  or  injury,  dislo- 
<?ation,  and  rheumatic  inflammation  of  the  joint.     The  arm  can- 


164  DISEASES   OF  THE   NERVOUS   SYSTEM. 

not  be  elevated  or  rotated  outward.  There  is  atrophy,  anaesthe- 
sia, and  sometimes  pain. 

Paralysis  of  the  Suprascapular  Nerves.— The  nerve 
goes  to  tlie  spinati  muscles,  teres  minor,  and  shoulder  joint.  Dis- 
ease of  this  nerve  alone  is  rare. 

The  supraspinatus  rotates  the  shoulder  in,  the  infraspinatus 
and  teres  minor  rotate  it  out.  When  paralyzed,  there  is  an  im- 
pairment of  rotation  and  some  impairment  of  elevation  of  the 
shoulder. 

Paralysis  of  the  Musculo-Spiral  Xerve  {Wrist  Drop, 
Lead  Palsy,  Compression  Paralysis).— T\\e  distribution  of  this 
nerve  is  given  in  the  table  and  cut.  Its  function  is  to  extend  and 
supinate  the  forearm,  to  extend  the  wrist  and  fingers,  and  to  ad- 
duct  and  abduct  the  fingers  slightly.  It  extends  directly  only 
the  last  or  ungual  phalanges,  the  first  and  second  phalanges  being 
extended  by  the  ulnar  nerve. 

Etiology. — The  musculo-spiral,  owing  partly  to  its  course,  is  the 
most  frequently  affected  by  paralysis  of  all  the  arm  nerves.  Pres- 
sure on  the  nerve  during  sleep,  especially  when  the  patient  is  in- 
toxicated, crutch-i3ressure,  fractures,  wounds,  tumors,  lead-poi- 
soning, arsenical,  alcoholic,  and  other  forms  of  multiple  neuritis 
are  the  causes  of  its  disordered  function. 

Symptoms. — The  symptoms  of  this  paralysis  are  "wrist  drop,'^ 
due  to  an  inability  to  extend  the  wrist  or  fingers.  The  first  and 
second  phalanges  can  be  extended  somewhat  by  the  interossei 
and  lumbricales,  but  the  last  jDhalanges  cannot  be  extended  at 
all.  The  first  finger  is  least  affected.  The  fingers  can  only  be 
slightly  abducted,  supination  is  generally  lessened  or  lost;  if  the 
lesion  is  high  up,  the  triceps  is  involved  and  the  power  of  extend- 
ing the  forearm  weakened.  There  may  be  atrophy  of  the  mus- 
cles and  degeneration  reaction.  A  swelling  over  the  tendons  of 
the  wrist  joint  may  occur.  Some  numbness  and  tingling  exists, 
and  occasionally  there  is  ana?sthesia  in  the  distribution  of  the 
radial  nerve  on  the  hand.  The  disease  lasts  but  a  few  weeks  if 
due  to  compression;  for  months  if  due  to  neuritis,  lead-poison- 
ing, or  severe  injury  of  the  nerve.  Eventually  recovery  takes 
place. 

When  the  disease  is  due  to  lead-poisoning  there  are  some 
peculiarities  in  its  course.  Thus  the  supinator  longus  usually  es- 
capes; the  palsy  begins  gradually  and  usually  involves  both 
arms;  it  may  extend  to  the  upper  arm.  Partial  degeneration 
reactions  are  present.  There  is  rarely  any  anesthesia  and  but 
little  pain.  There  is  a  lead  line  on  the  gum  and  a  history  of  con- 
stipation and  colic. 

In  al<;oholic  and  other  forms  of  multiple  neuritis  there  is  pain 
and  parajsthesia,  both  arms  are  involved,  and  the   flexors  and. 


DISEASES   OF   THE   SPINAL  NERVES. 


165 


other  forearm  muscles  are  somewhat  impHcated.  There  are 
marked  sensory  disturbances.     The  legs  are  also  affected. 

In  compression  ]jal!<y  the  supinators  and  often  the  triceps  are 
involved. 

When  the  lesion  of  the  nerve  is  high  up,  as  in  cnUch  pa- 
ralysis, there  is  but  little  anaesthesia,  and  that  is  found  on  the 
anterior  surface  of  the  forearm,  in  the  distribution  of  the  exter- 
nal and  internal  cutaneous  nerves.  Lesion  of  the  nerve  lower 
down  may  give  rise  to  some  anaesthesia  along  the  radial  border 
of  the  forearm  and  back  of  hand ;  but  the  anjesthetic  area  varies 
a  great  deal. 

The  diagnosis  of  the  paralysis  is  easily  made.  The  most  im- 
portant point  is  to  find  out  the  cause.  The  different  charac- 
teristics of  lead  palsy,  neuritic  palsy,  and  compression  palsy 
have  been  indicated  in  the  description  of  the  symptoms.  One 
must  be  sure  to  exclude  also  progressive  muscular  atrophy. 


Fig. 


Author's   Dynamometer  for  Measuring  the  Strength    of  Extensor 
AND  Flexor  Muscles  of  the  Forearm  and  Hand. 


The  treatment  consists  of  mechanical  measures  such  as  electri- 
city, massage,  the  application  of  rubber  muscles,  and  in  bad  cases 
the  fixation  of  the  forearm  and  hand  in  hyperextension  by  means 
of  a  splint  and  plaster-of -Paris  bandage  (Gibney).  Internally  in 
the  early  stage  it  is  best  to  administer  iodide  of  potassium  and 
sulphate  of  magnesium  (in  lead  palsy),  the  salicylates  or  nitrate 
of  silver  in  neuritis;  later,  hypodermic  injections  of  strychnia 
may  be  given.  Static  sparks,  galvanism,  and  other  forms  of  elec- 
tricity unquestionably  do  good  in  some  cases,  as  I  have  had  op- 
portunity to  prove. 

Paralysis  of  the  median  nerve  is  rare  as  an  isolated 
trouble,  and  is  almost  always  due  to  injury  or  neighboring  lesions. 
Embolism  of  the  axillary  artery  after  labor  has  produced  it. 

When  paralysis  occurs  the  grip  is  weakened.  Flexion  and  ab- 
duction of  the  thumb  and  flexion  of  the  first  and  second  fingers 
are  impaired.  Atrophy  of  the  thenar  eminence  may  occur.  The 
anaesthetic  area  varies,  but  is  well  shown  in  the  accompanying 
cut  from  Ruxton  (Fig.  75). 


166 


DISEASES   OF  THE  NERVOUS   SYSTEM. 


Paralysis  of  the  Ulnar  ^eryb.— Etiologi/.— The  ulnar 
nerve  is  rather  commonly  affected  by  paralysis,  the  occurrence 
ranking  next  in  frequency  to  musculo-spiral  palsy.  It  is  rarely 
affected  in  lead-poisoning,  but  is  usually  early  involved  in  pro- 
gressive muscular  atrophy.  It  is  sometimes  attacked  by  a  prim- 
ary degenerative  neuritis.     Injuries  are  the  common  cause. 

The  symptoms  are  shown  by  the  table.  The  hand  cannot  be 
closed  tightly,  the  little  and  ring  fingers  being  especially  weak. 
The  first  phalanges  are  drawn  back  and  the  second  and  third 
phalanges  flexed ;  wdien  the  interossei  and  lumbricales  atrophy, 
the  result  is  the"griflan  claw  "or  main  en  griffe.  The  fingers 
cannot  be  adducted  or  abducted  except  feebly. 

There  is  an^esthesia  over  the  area  of  distribution  of  the  ulnar 
(Fig.  75) ;  there  may  be  pain  and  tenderness. 


nil 

\\\ 

1 

i^^s. 

'''  B 

■ 

Fig.  75.— Area  op  Anaesthesia  in  Total  Paralysis  of  the  Median  Nerve. 

Symmetrical  Spontaneous  Ulnar  Neuritis.— A  form  of 
neuritis  of  the  ulnar  nerve  sometimes  occurs  which  has  certain 
peculiar  characters.  It  develops  slowly  in  persons  with  a  neuro- 
pathic history,  and  without  known  exciting  cause.  There  is  first 
some  pain  and  para?sthesia  in  the  region  of  the  ulnar  nerve  of  one 
hand;  this  i.s  followed  by  weakness  and  atrophy  of  the  muscles 
supplied  by  the  ulnar  nerve,  and  characteristic  deformity  appears. 
Auiesthesia  develops  coincidently.  The  other  hand  soon  becomes 
affected. 

The  disease  is  very  chronic,  and  complete  recovery  is  rare. 

It  is  probably  a  form  of  degenerative  neuritis. 


Spasmodic  Disorders  of  the  Arm.— The  arms  and  hands 
are  especially  suljject  to  tremors,  choj-eic  and  other  spasmodic 
movements.  The  only  spasmodic  disorders,  however,  which  may 
be  said  to  be  especially  located  there  are  writer's  cramp  and  allied 
occupation  neuroses.     These  are  described  elsewhere. 

Sensory  Disorders  of  the  Brachial  Nerves.— Ceryico- 
Brachial  Neuralgia.— This  is  a  painful  affection  involving 


DISEASES   OF   THE   SPINAL  NERVES.  167 

the  sensory  nerve  of  the  neck,  shoulder,  and  arm.  It  is  a  some- 
what rare  form  of  neuralgia,  and  like  most  other  forms  occurs 
oftenest  in  women,  before  middle  life.  The  ordinary  causes 
of  neuralgia  produce  it,  but  rheumatism  and  gout  are  rather 
prominent  factors.  Reflex  irritation  from  carious  teeth  and  uter- 
ine disease  have  been  found  to  be  causes.  It  occurs  symptomat- 
ically  in  locomotor  ataxia  and  other  cord  diseases.  A  low  grade 
of  neuritis  probably  often  exists. 

Symptoms. — It  begins  somewhat  gradually  with  aching  pains 
in  the  neck,  shoulder,  axilla,  and  along  the  course  of  the  nerves. 
The  pains  gradually  increase  and  are  usually  worse  at  night. 
The  pain  is  increased  by  use  of  the  arm  and  by  exposure.  Only 
one  arm  is  affected.  Painful  points  may  be  felt  in  the  axilla,  at 
the  lower  end  of  the  scapular,  over  the  deltoid,  over  the  ulnar 
near  the  wrist,  over  the  lower  part  of  the  radial  and  sometimes 
on  each  side  of  the  lower  cervical  vertebra?.  There  are  usually 
paraesthesife  and  numb  feelings.  If  there  is  a  complicating  neuri- 
tis, burning  sensations  are  felt  ("  causalgia  ").  There  may  be  anfes- 
thesia,  vasomotor  disturbances,  herpes,  and  muscular  weakness 
and  atrophy.  Brachial  neuralgia  generally  involves  all  the 
nerves  of  the  plexus.  If  special  nerves  are  involved  the  ulnar  is 
oftenest  affected,  next  the  musculo-spiral,  and  last  the  median. 

Digital  neuralgia  sometimes  occurs.  The  pain  is  often  lo- 
cated in  a  single  finger.  The  cause  is  usually  a  local  injury  or 
neuritis.  Sometimes  it  is  a  reflex  pain  due  to  some  remote  trou- 
ble.    In  a  few  cases  this  remote  trouble  is  uterine. 

Diagnosis. — The  etiological  diagnosis  is  most  important.  In- 
quiries as  to  a  rheumatic  or  gouty  element  should  be  made.  The 
presence  of  any  serious  amount  of  neuritis  would  be  shown  by 
local  tenderness  and  motor  weakness.  Organic  cord  disease  must 
be  excluded. 

The  prognosis,  if  the  neuralgia  is  functional,  is  good.  If  a 
neuritis  complicates  it,  it  is  more  serious.  If  the  neuritis,  how- 
ever, is  slight,  and  is  secondary  to  a  trauma,  or  is  rheumatic  or 
gouty,  the  prognosis  is  favorable.  Ordinary  attacks  last  about 
six  weeks. 

The  Treat?7ient.—SsdiGy\eite  of  potassium,  iodide  of  potassium, 
or  muriate  of  ammonia  should  be  given  and  in  large  doses.  Aco- 
nitia  and  gelsemium  are  of  not  much  value.  The  electrical  cur- 
rent, either  faradic  or  galvanic,  has  a  very  decided  effect  for 
good. 

Leeching  helps  some  cases.  Blisters  may  be  used  in  neuritic 
cases.  The  analgesic  drugs  like  phenacetin  and  antipyrine  and 
antifebrin  are  useful  symptomatically.  Hot  local  applications 
often  give  some  relief.  Colchicum  cures  some  cases  of  gouty 
origin. 


166  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Mif/ratifif/  neuritis  is  a  serious  but  rare  malady  which  deserves 
some  mention.  It  occurs  as  a  sequel  to  some  wound  of  or  opera- 
tion upon  a  nerve.  The  local  neuritis  extends  usually  up  the 
arm  (ascendinj?  neuritis).  It  is  accompanied  with  intense  pain, 
anaesthesia,  i)aralysis,  and  atrophy. 

The  disease  is  verv  chronic  and  intractable. 


Group  III.  The  Dorsal  Nerves. 

Anatomy  and  Physiology. — The  dorsal  nerves  are  twelve  in 
number.  The  first  is  the  laro:est  and  belongs  functionally  to  the 
arm  nerves.  The  dorsal  nerves  carry  motor  and  sensory  fibres  to 
the  voluntary  muscles,  skin,  and  other  tissues  of  the  trunk  wall. 
Tliey  also  carry  splanchnic  fibres  to  the  lungs  and  abdominal 
viscera.  They  divide  into  anterior  and  posterior  branches.  The 
anterior  form'  the  intercostal  nerves,  of  which  the  first  six  are 
distributed  to  the  wall  of  the  thorax  and  the  last  six  to  the  wall 
of  the  abdomen.  All  these  nerves  give  off  lateral  and  anterior 
branches.  The  posterior  branches  of  the  dorsal  nerves  are  small, 
and  supply  the  muscles  and  skin  of  the  back. 

Besides  the  above,  there  are  recurrent  branches  which  enter 
the  spinal  canal  and  supply  the  intraspinal  veins  and  mem- 
branes. The  first  six  dorsal  nerves  contain  fibres  which  enter 
the  sympathetic  and  supply  the  jDleura  and  lungs.  Fibres  from 
the  last  six  enter  the  sympathetic  and  supply  the  pelvic  viscera. 
The  intercostal  nerves  in  their  course  lie  part  of  the  way  beneath 
the  pleura;  they  also  pass  along  in  close  company  Avith  the  inter- 
costal artery  and  vein,  lying  just  above  these  in  the  groove  on 
the  internal  surface  and  inferior  border  of  the  ribs. 

The  ui)per  six  dorsal  nerves,  including  both  branches,  are 
mainly  inspiratory  in  function.  They  also  extend  and  rotate 
the  dorsal  and  cervical  vertebra.  The  lower  dorsal  are  expira- 
tory nerves ;  they  also  assist  in  compressing  the  abdominal  vis- 
cera, and  in  flexing,  extending,  and  rotating  the  spine. 

The  diseases  of  the  intercostal  nerves  are  almost  entirely  of  a 
sensory  character.  They  are  intercostal  neuralgia,  symptomatic 
side  pains,  herpes  zoster.  Paralyses  and  ansesthesise  occur  in 
connection  with  vertebral  and  spinal-cord  diseases. 

Intercostal  Neuralgia;  Side  Vai^q.— Etiology.— TYds  is 
a  very  common  neuralgia.  It  occurs  much  oftener  in  women 
(partly  from  corset-pressure)  than  in  men  (seven  to  one).  The 
favorite  age  is  twenty  to  thirty-five;  the  season,  winter.  An- 
aemia, neurasthenic  and  hysterical  conditions,  child-bearing, 
pelvic  disorder,  dyspepsia,  heart  disease,  malaria,  and  lead-poison- 
ing are  frequent  causes.  Exposure  and  muscular  strain  are  rare 
exciting  causes. 

Symptoms.— The  disease  comes  on  suddenly.  The  pain  in 
typical  cases  is  sharp  and  stabbing,  but  not  much  increased  by 
respiratory  movements.  There  are  tender  points  at  the  seat  of 
pain,  which  is  usually  greatest  over  the  side  at  the  exit  of  the 
lateral  nerve  branches.     Often  a  tender  point  is  felt  over  the  exit 


DISEASES   OF   THE   SPINAL   NERVES.  169 

of  the  dorsal  or  of  the  anterior  branch.  It  is  rare  to  find  all 
tiiree  points.  Tlie  disease  runs  about  the  course  of  facial  neu- 
ralgias, i.e.,  of  two  to  six  weeks,  but  it  is  sometimes  very  obsti- 
nate, lasting  for  many  months.  The  sixth  to  tenth  nerves  are 
those  oftenest  involved.  The  left  side  is  more  susceptible  than 
the  right  (three  to  one). 

Pathology. — In  most  cases  the  nerve  is  irritated  by  poor  or 
poisoned  blood.  In  a  minority  of  cases  the  pain  is  reflex  from 
stomach,  pelvis,  or  heart.     Sometimes  there  is  a  neuritis. 

Diagnosis. — Probably  one-half  the  pains  in  the  side  are  myal- 
gic  in  nature,  and  should  be  classed  as  pleurodynia.  These  pains 
can  be  distinguished  by  the  history  of  their  origin  and  of  rheu- 
matic influences,  by  their  difTuseness  and  dulness,  by  the  great 
tenderness  on  pressure,  and  the  pain  produced  on  taking  a  deep 
breath. 

There  is  another  considerable  proportion  of  cases  in  which 
the  pains  are  mainly  neuralgic,  but  yet  there  are  some  evidences 
of  muscular  complications.     Some  of  these  pains  are  reflex. 

In  the  third  class  of  cases  there  is  the  pure  stabbing  neund- 
gia.  The  diagnosis  is  based  on  the  exclusion  of  pleurisy,  rheu- 
matic and  reflex  causes,  by  the  character  of  the  pain,  and  the 
presence  of  tender  points. 

Prognosis. — The  iDrognosis  is  good,  except  for  a  few  chronic 
cases  due  probably  to  a  degenerative  neuritis.  In  some  of  these 
cases  there  is  lead -poisoning. 

Treatment.— The  most  efficacious  treatment  is  a  blister  and 
ferruginous  tonics  with  quinine.  In  all  cases  the  heart,  pleura, 
stomach,  and  pelvic  organs  must  be  examined,  and  any  disorder 
relieved.  Iodide  of  potassium  and  chlorodyne  have  cured  some 
very  bad  cases  in  my  experience.  If  there  is  a  rheumatic  and 
muscular  element,  give  salicylates  or  the  analgesics,  apply  heat, 
and  secure  rest  by  adhesive  straps. 

Mammary  xeuralgia  (mastody:xia)  is  a  form  of  intercostal 
neuralgia  involving  the  anterior  and  lateral  branches  of  the  three 
or  four  upper  dorsal  nerves. 

Etiology. — It  is  caused  by  local  tumors,  or  it  may  be  an  essen- 
tial neuralgia.  The  causes  in  the  latter  class  are  anaemia,  pen- 
dent breasts,  pressure  from  badly  fitting  corsets,  and  injury. 

Mammary  neuralgia  also  occurs  in  hysterical  women  and  young 
girls  sexually  precocious;  it  may  occur  in  pregnancy  and  during 
lactation.  Many  mammary  pains  are  due  simply  to  local  dis- 
order of  the  gland. 

^yni2:ttonis.—lslviU\\u^Y\  neuralgia  is  unilateral,  often  very  se- 
vere, and  if  it  occurs  in  middle  life  is  liable  to  cause  much  men- 
tal depression  from  fear  of  cancer. 

The  treatment  depends  upon  the  cause.     It  requires  general 


170  DISEASES  OF  THE   NERVOUS   SYSTEM. 

tonic  measures  and  attention  to  the  proper  support  and  protec- 
tion of  the  gland. 

HERrES  Zoster,  Dermatitic  Neuritis  {Shingles).— Almost 
the  only  recognized  form  of  neuritis  of  the  intercostal  nerves  is 
known  under  the  name  of  herpes  zoster.  This  is  an  acute  derma- 
titis, secondary  to  the  neuritis. 

Etiohxjy.—ltB  causes  are  wounds,  infections,  tlie  morphine 
habit,  rheumatic,  gouty,  and  syphilitic  poisons,  and  emotional 
intiuences.  The  inflannuation  affects  not  only  the  nerves,  but 
the  spinal  ganglia. 

Symptoms.— It  begins  gradually  with  the  development  of  pain 
and  a  herpetic  eruption  upon  one  side  of  the  trunk.  It  gener- 
ally involves  the  lower  dorsal  nerves.  The  eruption  follows  the 
course  of  the  nerve,  rarely  extending  to  the  opposite  side.  The 
pain  gradually  subsides,  and  the  disease  itself  runs  its  course  in 
a  few  weeks. 

Treatment. — In  the  early  stage  the  galvanic  current  is  effica- 
cious. Local  anodynes  and  i:)rotective  ointments  may  be  applied. 
Anti-rheumatics  and  analgesics  are  to  be  administered  internally. 


Group  IV.  The  Lumbar  Nerves. 

Anatomy  and  Physiology. — The  lumbar  nerves  are  five  in 
number.  The  posterior  branches  supply  the  erector  spin?e,  in- 
terossei,  multifidce  spinse  and  interspinales,  and  also  the  skin  of 
the  back.  The  anterior  branches  of  the  upper  four  unite  to 
form  the  lumbar  j^^^xtis.  The  fifth  or  lumbo-sacral  nerve  sends 
most  of  its  fibres  to  the  sacral  plexus.  The  branches  of  the  lum- 
bar plexus  are:  (1)  the  ilio-inguinal,  (2)  ilio-hypogastric  (from 
first  lumbar),  (3)  genito-crural  and  (4)  external  cutaneous  (mainly 
from  the  second),  (5)  obturator  (from  third  and  fourth  lumbar), 
(0)  the  anterior  crural  (from  second,  third,  and  fourth— Fig.  7(5). 

The  first  four  branches  of  the  plexus  are  comparatively  short 
and  sujiply  sensation  to  the  abdominal  Avail  and  external  geni- 
tals. The  last  two  are  longer  and  supply  the  hip  and  knee  joints, 
the  nmscles  of  the  anterior,  inner,  and' outer  part  of  the  thigh, 
the  skin  over  this  region  and  the  inner  side  of  the  leg  and  dor- 
sum of  the  foot  (Fig.  7(3). 

The  diseases  of  the  lumbar  nerves  and  plexus  so  far  as  they 
form  independent  disorders  are  mainly  the  neuralgias. 

Paralyses  and  spasmodic  troubles  of  the  lumbar 
nerves  are  not  rare,  but  are  usually  symptomatic  of  some  ex- 
trinsic and  often  serious  disease. 

Etiology.— Hence  it  is  Avell  to  catalogue  here  those  affections 
which  may  produce  lumbar  palsies  or  spasms.  They  are  pelvic 
tumors  or  injuries,  impacted  faeces,  caries  of  the  spine,  psoas 
abscess,  obturator  hernia,  hip  disease,  and  pressure  of  the  foital 
head. 


DISEASES   OF   THE   SPINAL   NERVES. 


171 


iSy?npto7?is.— When  the  upper  two  lumbar  nerves  are  involved, 
only  sensory  symptoms  in  the  distribution  of  their  branches 
occur  (Fig.  7G).  If  the  next  two  are  also  involved,  there  may  be 
trouble  in  extending  the  leg  and  flexing  the  hip  on  the  trunk. 
The  patient  cannot  raise  himself  to  a  sitting  posture.  If  there 
is  irritation  and  spasm,  the  thigh  is  drawn  up  and  adducted. 

In  making'  a  diagnosis  of  lumbar-nerve  disease,  one  should 
remeiuber  that  of  the  six  branches  of  the  plexus  the  upper  four 
are  mainly  sensory,  the  lower  two  mixed  nerves. 


Sartorius;  anterior )     Anterior 
thigh  muscles.      *'  crural  nerve 

Adductors  and     /  ,-,Kf„,.„f^„ 
external  rotators  -^'^t"i^*or     V- 
of  the  thigh.     )      "«rve. 
Superior 
(  gluteal  nerve. 


Glutei. 


Pyriforinis     )  -vi.mp.jK- 
obturator  int.  --\\'^f;^^ 
gemelli.     )    'leives. 

Quad,  fern.,   (  Small  sciatic 
Glut.  max. )        nerve. 

Adduct.  magn.  flexors]   p,.„_i. 

of  ki\ee,  extensors        ''i„H^ 

of  loot,  calf  muscles.  /  ^^•'^''^ 

foot  muscles.         J 


uerve. 


Bladder,      1 
perineum,  i   P*udic 
genitals,      (  nerve, 
sphincters.  J 


Fig.  76.— Diagram  showing  the  Origin  and  Distribution  of  the  Motor  and 
Sensory  Nerves  op  the  Lower  Limbs. 


In  paralysis  of  the  obturator  nerve  there  is  loss  of  power  to 
adduct  the  thigh  and  cross  the  leg,  and  weakness  of  outward  ro- 
tation of  the  thigh.  Anyesthesia  over  the  inner  side  of  the  thigh 
may  be  present. 

In  j^aralysis  of  the  anterior  critral  nerve  there  is  weakness  of 
the  muscles  of  the  anterior  surface  of  the  thigh,  loss  of  power  of 
extending  the  leg,  and  anaesthesia  or  pain  over  the  crural  area. 

Paralysis  of  the  posterior  branches  of  the  himbar  nerves 
causes  weakness  or  paralysis  of  the  erectors  of  the  spine.  The 
lumbar  curve  is  very  greatly  exaggerated,  the  shoulders  being. 


172  DISEASES   OF   THE   NERVOUS   SYSTEM. 

thrown  far  back  and  the  behy  protruding.  This  condition  occurs 
in  progressive  muscular  atrophy,  jDarticularly  in  the  pseudo- 
hyi)ertropliic  form. 

Neuralgias  axd  Reflex  Paixs  of  the  Lumbar  Xeryes. 
—MioIogt/.—^eurai\gms  of  the  upper  branches  of  the  lumbar 
nerves  are  called  lumbo-abdominal.  They  occur  oftener  in 
women  and  usually  after  the  thirtieth  year.  To" the  ordinary 
causes  of  neuralgia  we  add  straining,  constipation,  and  pelvic  dis- 
ease. True  essential  neuralgia  is  rare;  but  myalgic  and  reflex 
pains  from  uterine  disease  are  very  conimon,  especially  in  women. 

Symptoms.— There  is  pain  in  the  loins,  back,  and  buttocks, 
extending  down  to  the  hypogastrium  or  genitals  on  one  side. 
The  pain  in  the  back,  however,  is  often  bilateral.  Painful  points 
may  be  found  after  a  time,  as  in  intercostal  neuralgia.  Some- 
times the  pain  is  located  in  the  side  of  the  penis  (penile  neuralgia). 
Neuralgia  of  the  long  lumbar  branches  is  called  femoral  or  crural. 
A  common  form  of  this  constitutes  what  is  called  painful  thigh. 
The  patient  complains  of  pain  in  the  front  of  the  knee  and  the 
anterior  and  outer  parts  of  the  thigh,  but  has  no  pain  posteriorly 
and  none  below  the  knee.  The  internal  branches  of  the  anterior 
crural  nerve  do  not  seem  to  be  afTected,  while  the  middle  and 
external  cutaneous  branches  and  the  genito-crural  nerve  are  in- 
volved. 

Reflex  axd  Symptomatic  Paixs.— Disease  of  the  hip  or  of^ 
the  sacro-iliac  joint  or  vertebrae  may  cause  a  reflex  pain  in  the  ob- 
turator nerve,  localized  especially  in  the  knee  and  back  of  this 
joint.  The  foetal  head  sometimes  compresses  these  branches, 
causing  a  symi)tomatic  neuralgia.  Diseases  of  the  internal  geni- 
tal organs  are  esi:)ecially  liable  to  cause  reflex  pain  in  the  lumbar 
nerves.  Diseases  of  the  external  genitals  and  bladder  more  often 
reflect  pains  upon  the  sacral  nerves.  In  biliary  colic  pains  are 
felt  in  the  ilio-inguinal  and  hypogastric  nerves.  Local  disease  of 
the  psoas  muscle  or  iHacus,  in  the  neighborhood  of  Poupart's 
ligament,  causes  pains  in  the  lumbar  nerves.  Lumbar  neural- 
gias generally  run  a  favorable  and  not  very  long  course. 

I)iag7iosis.— They  are  distinguished  from  lumbago  by  the  uni- 
lateral position,  the  distribution  and  paroxysmal  character  of  the 
pain,  and  the  lack  of  severe  suffering  on  motion  and  pressure ; 
the  tender  points  and  the  absence  of  any  organic  disease. 

Lumbago  comes  on  suddenly,  Avith  a  history  of  exposure,  is 
confined  to  a  single  group  of  muscles,  which  are  tender  on  deep 
pressure.  In  lumbar  sprain  the  onset  is  also  sudden,  with  a  his- 
tory of  injury,  great  local  tenderness,  and  evidences  of  trauma. 

The  treatment  is  the  same  as  that  for  neuralgia  in  general. 
The  frequent  presence  of  pelvic  disease  and  of  anaemia  and  a 
rheumatic  history  nuist  be  borne  in  mind. 


I 


DISEASES   OF  THE   SPINAL  NERVES.  173 


Group  V.    The  Sacral  Nerves. 

Anatomy  and  Physiology. — The  sacral  nerves  are  five  in  num- 
ber. The  first  four  divide  into  anterior  and  posterior  branches. 
Tlie  fifth  has  no  anterior  branch.  The  posterior  branches  es- 
cape through  the  posterior  sacral  foramina  and  supply  the  mul- 
titidus  spin«3  and  the  skin  over  the  sacrum  and  coccyx. 

The  first  three  anterior  branches,  with  the  lumbo-sacral  nerve 
and  a  branch  from  the  fourth  sacral,  unite  to  form  the  sacral 
plexus.  This  lies  upon  the  pyriformis  muscle  in  the  pelvis,  and 
escapes  at  the  lower  j^art  of  the  sacro-sciatic  foramen.  The  great 
mass  of  the  fibres  go  to  make  up  the  sciatic  nerve. 

The  roots  of  origin  of  the  sacral  and  coccygeal  nerves  form  the 
canda  equina. 

The  branches  of  the  sacral  plexus  are  the  superior  gluteal, 
muscular,  small  sciatic,  inferior  gluteal,  pudic,  great  sciatic,  per- 
forating, cutaneous,  and  articular.  These  are  distributed  to  the 
muscles,  skin,  and  joints  of  the  buttocks,  thighs,  legs,  and  feet. 
Their  distribution  is  shown  in  Fig.  76. 

The  sacral  nerves  are  the  main  agents  in  station  and  locomo- 
tion. They  control  the  legs  entirely,  also  the  posterior  muscles  of 
the  thigh  and  buttocks ;  they  give  sensation  to  these  parts.  They 
carry  also  fibres  that  regulate  the  sexual  function,  bladder,  and 
rectum.  From  the  sacral  portion  of  the  cord  there  is  an  outflow 
of  nerves  to  the  sympathetic,  thence  to  the  pelvic  organs. 

The  diseases  of  the  sacral  nerves  may  be  classified  in  a  similar 
way  to  those  of  the  brachial  plexus.  I  shall  here  also  follow  the 
clinical  method  and  study  the  paralyses,  spasmodic  disorders,  and 
neuralgias  of  this  group  of  nerves. 

Peripheral  Lsfi  Palsies.— Paralyses  of  the  lower  limbs 
from  disease  of  the  nerves  may  be  either  combined  or  single,  just 
as  is  the  case  with  arm  palsies. 

A  combined  sacral  palsy  is  one  in  which  all  or  nearly  all  of  the 
branches  of  the  sacral  plexus  are  involved. 

Etiology.— ^noh  palsies  are  due  to  much  the  same  causes  as 
those  affecting  the  lumbar  nerves,  viz.,  injury,  dislocation,  hip 
disease,  tumors,  and  neuritis.  Hysteria  may  cause  a  functional 
sacral  palsy. 

Sympto?ns.— The  symptoms  are  indicated  by  a  study  of  the 
distribution  of  the  nerves,  varying,  however,  in  degree.  The  foot 
cannot  be  moved ;  the  leg  can  be  slightly  flexed  by  the  anterior 
crural,  but  not  extended ;  the  thigh  cannot  be  drawn  back  freely 
or  rotated  perfectly.  There  is  anaesthesia  over  the  distribution 
of  the  sacral  nerves;  pain  may  be  present;  wasting  and  vaso- 
motor and  secretory  disturbances  occur  unless  the  paralysis  is 
functional. 

The  course  depends  on  the  severity  of  the  lesion.  If  the  nerve 
is  totally  cut  or  torn  across,  it  may  require  one  or  two  years  for 
perfect  recovery,  which,  however,  occurs  if  the  severed  ends  are 
properly  approximated. 


174  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  diagnosis  of  a  sacral  palsy  is  based  on  the  history  and  on 
the  distribution  of  the  anaesthesia,  and  of  the  muscular  paralysis. 
The  sacral  nerves  do  everything  for  the  lower  limb  except  extend 
the  leg,  flex  and  adduct  the  thigh,  and  to  some  extent  rotate  it. 
They  supply  sensation  equally  extensively  (see  Fig.  76). 

The  distinction  from  spinal-cord  disease  is  chiefly  based  on 
the  unilateral  symptoms,  the  absence  of  disorder  of  the  sphincters, 
and  the  combination  of  paralysis,  wasting  and  sensory  troubles, 
in  the  course  of  the  sacral  nerve. 

Sixgle-Nerve  Sacrai,  Palsies.— The  symptoms  cf  paralysis 
of  single  nerves  are  indicated  by  their  function.  The  nerves 
rarely  affected  are  the  superior  gluteal,  muscular,  and  small 
sciatic.  The  nerve  oftenest  affected  is  the  great  sciatic,  and 
especially  its  anterior  tibial  branch.  In  the  latter  case  a  condi- 
tion called  "  drop  foot"  is  produced. 

In  thepr^f/io/o^^  and  treatment  of  sacral  palsies  there  is  noth- 
ing esppcial  that  can  be  said. 

Spasmodic  Disorders  of  the  Sacral  Xerves.— Tremor, 
rigidity,  clonic  and  tonic  spasms,  myoclonus,  athetoid  movements, 
all  affect  the  lower  extremities,  but  they  are  almost  invariably 
part  of  some  general  or  central  disorder,  such  as  chorea,  paraly- 
sis agitans,  hysteria,  etc.  Under  the  head  of  occupation  neuroses 
there  occur  certain  rare  spasmodic  troubles  special  to  the  legs. 
Saltatory  spasm  involves  the  legs  alone.  These  disorders  are, 
however,  general  neuroses. 

Sciatica  (Neuralgia  op  the  Sciatic  Nerve,  Sciatic 
Neuritis). — This  is  a  form  of  neuralgia  occurring  in  middle  life 
and  characterized  by  intense  pain  in  the  course  of  the  sciatic 
nerve.     A  large  proportion  of  the  cases  are  due  to  a  neuritis. 

Etiology. — The  disease  occurs  three  times  as  often  in  men  as  in 
women,  and  is  the  only  neuralgia  of  which  this  can  be  said.  Most 
cases  in  this  country  occur  betw^een  the  ages  of  forty  and  flfty; 
next  between  thirty  and  forty.* 

The  gouty  and  arthritic  diathesis,  occupations  which  lead  to 
exposure  and  strain,  predispose  to  the  disease.  It  is  not  rare, 
therefore,  among  laboring  men.  In  younger  persons  a  neurotic 
constitution  predisposes  to  the  disease,  and  in  this  class  the 
trouble  is  more  truly  of  a  neuralgic  character  and  less  of  a  neu- 
ritis. 

Most  cases  occur  in  the  autumn,  and  winter.  The  exciting 
causes  are  constipation,  pressure  from  hard  seats,  exposure,  mus- 
cular strain  from  heavy  work,  and  pelvic  disorders.    Symptomatic 

*  Personal  statistics  (102  cases)  and  those  of  Dr.  L.  Putzel  (53  cases)  give  males. 
Ill;  fenaales,  44.  Ages:  10-20,  4;  21-30,  30;  31-40,  43;  41-50,  44;  51-GO.  18;  61-70,  12; 
71-80,  4. 


DISEASES   OF   THE   SPINAL   NERVES.  175 

sciatica  may  he  caused  bj^  the  pressure  of  pelvic  tumors,  injury 
to  tlie  nerves,  inflammation,  vertebral  and  spinal  disease;  sciatica 
occurs  in  diabetes  and  in  phthisis.  In  elderly  persons  of  a  rheu- 
matic constitution  inflammatory  processes  about  the  hip  joint 
complicate  or  cause  the  neuralj^ia. 

JSt/mptoms. — The  disease  begins  rather  suddenly.  Pain  is  felt 
in  the  back  of  the  thigh,  running  down  the  leg  in  the  course  of 
the  nerve.  Generally  it  is  most  marked  in  the  thigh,  extending 
up  often  into  the  lumbar  region.  Sometimes  the  disease  begins 
like  a  lumbago;  more  rarely  pain  is  first  felt  in  the  calf  or  foot. 
The  pain  is  increased  by  motion,  and  the  patient  holds  himself  in 
a  constrained  position.  The  peivis  is  tilted  up  toward  the  sound 
side  and  the  trunk  inclined  over  to  the  diseased  side.  After  a 
time  this  leads  in  some  cases  to  a  characteristic  deformity  (sciatic 
scoliosis)  in  which  the  convexity  of  the  curve  of  the  vertebral 
spines  is  directed  toward  the  diseased  side.  The  joain  is  almost 
continuous,  with  i^aroxysms  of  great  severity,  which  often  occur 
at  night.  During  these  paroxysms  the  pain  is  sharp,  burning, 
and  lancinating.  In  the  intervals  it  is  dull.  Besides  the  pains 
the  patient  suffers  from  feelings  of  numbness,  tingling,  and  a 
sense  of  coldness  and  weight  in  the  affected  limb.  There  are  al- 
most always  tender  points  over  the  course  of  the  nerve.  These 
may  be  found  at  the  sciatic  notch,  at  the  middle  of  the  hip,  be- 
hind the  knee,  just  below  the  head  of  the  fibula  in  the  middle  of 
the  calf,  behind  the  external  malleolus,  and  on  the  back  of  the 
foot  (Fig,  77). 

A  pain  running  up  the  back  of  the  thigh  may  be  caused  by 
pressure  over  the  back  of  the  knee  when  the  leg  is  extended  at  a 
little  more  than  a  right  angle.  This  is  diagnostic  (Gowers).  If 
the  patient  lies  on  his  back  and  the  leg  is  kept  extended,  and 
then  the  whole  limb  brought  slowly  up  until  it  is  at  an  acute 
angle  with  the  trunk,  a  sharp  pain  in  the  sciatic  notch  is  felt ; 
this  too  is  diagnostic. 

Anaesthesia  over  the  course  of  the  nerves  occurs  very  rarely. 
When  present,  it  indicates  a  severe  neuritis  or  injury  to  the  nerve. 

Muscular  wasting  and  weakness  occur  after  a  time,  and  in  old 
and  severe  cases  partial  electrical  degeneration  reactions  may  be 
observed.  Herpetic  eruptions  ov^er  the  course  of  the  nerve  occur 
in  rare  cases.  The  affected  limb  usually  feels  colder  and  shows 
evidence  of  enfeebled  vasomotor  supi^ly. 

The  disease  usually  lasts  two  or  three  months;  not  rarely  it 
lasts  six  months  or  even  a  year  or  more.  It  has  been  known  to 
extend  slowly  upward  and  involve  the  sacral  plexus  or  even  the 
spinal  cord. 

FatJiolog)/.— The  trouble  is,  as  already  stated,  a  chronic  peri- 
neuritis in  the  majority  of  cases. 


i:g 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


Diagnosis.— Scmtica  has  to  be  distinguished  from  hip-joint 
disease,  organic  disease  of  the  eaada  equina  or  cord,  muscular 
pains  in  the  hip  and  leg,  and  from  pains  caused  by  tumors.  Pure 
sciatic  neuralgia  ought  also  to  be  distinguished  from  sciatic  neu- 
ritis. A  consideration  of  the  facts  already  given  ought  not  to 
make  the  diagnosis  difficult. 

Pure  sciatic  neuralgia  occurs  in  eary  life  and  is  not  accom- 
panied with  much  local  tenderness.  There  is  no  paralysis  or 
wasting  of  the  limb.  Double  sciatica  is  most  always  symptomatic 
of  diabetes  or  organic  disease.     True  sciatica  is  rarely  double. 

P;-o^«o.s'/.s'.— Almost  all  cases  get  well  in  from  three  to  six 


Fig.  77.— Showing  the  Tender 
Points  in  Sciatica. 


Fig.  78.  Plantar  Form  of  Sciatica;  Plantar 
Neuritis,  showing  area  of  i^ain  (Mitchell^. 


months.     Severe  attacks  in  people  over  forty  are  the  most  intrac- 
table.    Relapses  occur,  but  not  as  a  rule. 

Treatment. — In  all  cases  w^hich  are  seen  early,  the  most  im- 
portant indication  is  rest.  The  patient  should  be  put  to  bed, 
and  the  whole  lower  extremity  secured  in  a  Thomas  splint  ex- 
tending from  ankle  to  axilla.  Ice-bags  or  linseed  poultices  or 
leeches  should  then  be  applied  over  the  course  of  the  nerve.  A 
blue  pill  (gr.  v.)  may  be  given  twice  daily  at  first.  In  less  severe 
or  older  cases  large  blisters  should  be  applied  over  the  nerve  in 
the  thigh,  and  the  application  repeated  in  a  Aveek.  If  there  is  a 
rheumatic  history,  potassium  salicylate  or  iodide  should  be  given 
in  full  doses.  The  bowels  must  be  freely  opened.  Hypodermic  in- 
jections of  morphia  or  cocaine  (gr.  I)  may  be  needed  for  a  few  days, 
the  cocaine  being  repeated  if  necessary.  AVhen  the  disease  has  be- 
come more  chronic  a  strong  galvanic  current  may  be  given  daily 


DISEASES   OF   THE   SPINAL   NERVES.  177 

with  large  electrodes,  one  over  the  lumbar  region  or  sciatic  notch ; 
the  other,  which  should  be  the  positive  pole,  over  the  leg  and  foot.' 
As  so-called  specific  remedies  we  have  oil  of  turpentine  in  doses 
of  fifteen  drops  t.  i.  d.,  and  this  may  be  advantageously  com- 
bined with  oil  of  gaultheria.  Massive  doses  of  antifebrin  or  anti- 
pyrine  sometimes  stop  the  pains  (gr.  x.,  q.  2  h.).  There  are  a  great 
many  local  remedies  which  at  times  prove  useful.  Among  these 
mustard  plasters,  menthol,  chloroform  liniment,  setons,  acupunc- 
ture, cups,  and  the  actual  cautery  and  chloride  of  methyl  can 
be  recomniended.  Bandaging  the  limb  in  sulphur  to  which  a 
little  menthol  is  added  is  often  very  efficacious.  Kneading  the 
nerve  with  a  glass  rod  and  an  anodyne  ointment  is  sometimes 
beneficial.  Very  little  can  be  expected  from  nerve-stretching, 
but  it  may  be  tried  as  a  last  resort.  If  tried,  however,  great  cau- 
tion should  be  exercised  in  pulling  on  the  nerve.  Not  over  thirty 
to  forty  pounds  pull  should  be  used.  The  operation  of  cutting 
down  on  the  nerve  and  dissecting  off  the  sheath  for  a  space  of 
several  inches  may  be  tried. 

Plaxtar  Neuralgia.— In  rare  cases  the  pain  of  sciatic  neural- 
gia is  limited  to  the  plantar  nerves,  and  is  accompanied  with  partes- 
thesia  and  even  ansestliesia  of  this  region.  The  condition  here  is 
probably  a  neuritis  combined  sometimes  with  arthritic  changes. 
Erythromelalgia  may  be  regarded  as  a  form  of  plantar  neuralgia. 

CoccYGODYXiA  is  a  neuralgia  affecting  the  lower  posterior 
branches  of  the  sacral  nerves.  It  occurs  oftenest  in  women  and 
is  caused  by  exposure,  injury,  and  labor.  Coccygeal  pains  occur 
in  spinal  irritation  and  reflexly  from  pelvic  disease.  The  disease 
is  a  most  annoying  one,  as  it  interferes  with  sitting  and  walking. 
There  is  often  also  pain  at  stool,  and  the  parts  are  tender  to  pres- 
sure. The  disease  is  usually  one  involving  the  fibrous  structures 
of  the  coccyx,  and  is  more  an  articular  and  bony  than  nervous 
disorder.  Surgical  treatment,  such  as  amputation  of  the  coccyx, 
may  be  needed. 

Recapitulation.— The  student  should  understand  that,  de- 
spite the  great  clinical  variety  of  peripheral  nervous  disease,*there 
is  an  underlying  unity  as  regards  the  pathological  condition,  the 
cause  and  the  symptoms.  In  order  that  this  may  be  clearly 
brought  out,  I  append  the  following  tables. 

The  student  will  remember  that  the  causes  of  nearly  all  periph- 
eral nerve-diseases  can  be  classed  under  the  following  heads: 

Heredity  and  neuropathic  constitution;  sex;  age — infant, 
youth,  etc.;  injuries;  diatheses — rheumatism,  gout,  diabetes; 
exposures ;  mental  and  j^Jiysical  excesses ;  infections — chronic, 
e.(/.,  syphilis  and  the  febrile;  poisons — narcotic,  metallic,  etc.; 
ana'mia  and  marasmus  ;  arteriosclerosis. 

The  table  as  given  applies  ro  afl  peripheral  nerves.  The 
cranial  nerves  are,  however,  more  affected  by  syphilis  and  brain 
disease. 

12 


^8  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Table  I.— Peripheral  Nervous  Diseases— Types  axd 
Causes. 


Type  of 
1.  Anaemia  and 


Disease. 
Hyperaemia ; 


r  Multiple 
neuritis. 


Inflammation.    ^ 


Degenerations. 

Destruction. 
Tumors. 


Functional 
neuroses. 


I  Mono- 
id     neuritis. 


f  Primary. 

\ 

I  Secondary 


\  Single. 
]  Multiple. 
fWith   signs 
of     nerve 
I     irritation. 

',  Or  of  nerve 
I     depres- 
sion. 


Principal  Causes. 

f  Female,  young  adults.  Poisons — 
alcohol, arsenic;  Infections — feb- 
rile, endemic;  Diatheses — rheu- 
matism, Exposures. 

fMale,  infants,  adults.  Injuries, 
over-use;  Poisons — lead;  Infec- 
tions—febrile, syphilis;  Diathe- 
ses— gout,  rheumatism. 
Male,  mid-age,  senility.  Maras- 
mus, Loc.  ataxia ;  Poisons — lead ; 
Infections — diphtheria. 
Injury,  destruction,  or  inflamma- 
tion   of    nerve    or    its    trophic 

(^     centre. 

i  Injuries,  compression  by  tumors, 

i     etc. 
Heredity,  injuries,  operations. 
Chronic  infections. 

f  Heredity,     neuropathy,     female, 

^      youth,  and  mid-age.    Over-use. 

t     Poisons — narcotic,  metallic. 

f  Diatheses — rheumatism,  gout,  dia- 

!      betes;  Infection — syphilis;  Anae- 

I      mia,  Arterio-sclerosis ;  Malnutri- 

L     tion. 


The  symptoms  of  peripheral  nervous  diseases  are  shown  in 
irritation  and  excess,  diminution  and  loss,  and  perversion  of 
function.  Since  nerves  are  sensory,  motor,  visceral,  trophic,  re- 
flex, etc.,  many  combinations  of  symptoms  result.  These  have 
been  ahead v  described. 


Table  II.— Peripheral  Nervous  Diseases— Types  axd 
Symptoms. 


Type. 
Aucemva  and  Hyperaemia. 


Multiple 
neuritis. 


Inflammation.   -{ 


Mono- 
neuritis. 


Principal  Sj^mptoms. 

j  Sensory    irritation;  neuralgia, 

(  numi3ness. 
Acute  onset,  chronic  course.  At 
first  sensory  irritation, 'followed 
by  loss ;  motor  weakness; 
trophic  and  vasomotor  disturb- 
ances ;  recovery  one  to  two  years. 

'  Acute  or  chronic :  nerve  irritation, 
later  diminution  and  loss  of 
function ;  tropliic,  vasomotor, 
and  secretory  disorders;  recov- 
ery the  rule,  one-quarter  to  one 
and  one-half  vears. 


DISEASES  OP  THE  SPINAL  NERVES. 


179 


Degenerations.  { 


Destruction. 

Tumors. 

Functional 
neuroses. 


,_,  .  fGrraduallossof  function,  little  irri- 

r  Primary.       {      tation,    much    trophic  disturb- 
t     ance ;  very  chronic ;  rarely  a  cure 

.  f  Rapid  loss  of  function,  a  little  irri- 

L  Secondary.  {      tation ;  course  chronic ;  cure  f re- 
t     quent. 

f  Sudden  irritative  symptoms,  pain, 
i  spasm,  etc.;  then  loss,  like  a 
t     secondary  degeneration. 

j  Single.  (  Irritative  symptoms.  Or  no  symp- 

i  Multiple.       }     toms,  chronic. 

fOfirritativej  Neuralgia,    paresthesia,    oedema, 
kind.  I     local  asphvxia,  spasm. 

Of     depres-  \  Occupation  palsies,  reflex  palsies, 
sive  kind.  /     etc. 


1 


CHAPTER  X. 

DISEASES  OF  THE   SPINAL  CORD. 

AXATOMY  AXD    PHYSIOLOGY, 

Anatomy.— The  spinal  cord  is  a  slender,  cylindrically  shaped 
organ.  It  is  from  42  to  45.7  cm.  (sixteen  and  one-half  to  eig'hteen 
inches)  long,  being  shorter  absolutely  and  relatively  in  women. 
Its  weight  is  about  thirty-three  grams  (one  ounce). 

It  is  suspended  in  the  vertebral  canal,  where  it  reaches  in  all 
persons  over  one  year  of  age  as  far  down  as  the  second  lumbar 
vertebra.  In  new-born  infants  it  extends  to  the  third  lumbar 
vertebra. 

It  is  divided  into  cervical,  dorsal,  lumbar,  and  sacral  portions, 
corresponding  with  the  nerves  it  gives  off.  These  are  respectively 
four,  ten  and  one-half,  two,  and  one  and  one-half  inches  long 
(see  Fig.  79).  Its  shape  on  cross-section  is  nearly  round,  except 
in  the  lower  cervical  region,  where  it  is  flattened  antero-posteri- 
orly.  Its  average  diameter  is  1  cm.  (two-fifths  of  an  inch).  It 
has  two  swellings  or  enlargements,  the  cervical  and  lumbar. 
Their  position,  size,  and  extent  are  shown  on  the  diagram.  Its 
specific  gravity  is  1030. 

It  is  surrounded  by  three  membranes,  all  of  which  are  continu- 
ous with  the  corresponding  envelopes  of  the  brain.  They  are  the 
dura  mater,  the  arachnoid,  and  the  pia  mater  (Fig.  80). 

The  dura  mater  is  the  external  covering.  It  is  a  long  sac  at- 
tached to  the  edge  of  the  foramen  magnum  above  and  extending 
down  until  its  walls  fuse  together  at  the  level  of  the  second  sacral 
vertebra.  Its  cavity,  therefore,  is  much  longer  than  the  spinal 
cord.  It  is  attached  to  the  bony  canal  at  its  lower  end,  and  is 
held  loosely  by  twenty-two  lateral  ligaments  (/.  denticiilata) 
throughout  its  length. 

The  arachnoid  is  a  thin,  semi-transparent  membrane  lying 
loosely  over  the  cord  and  roots. 

Internally  it  is  connected  by  numerous  connective-tissue  fila- 
ments with  the  innermost  membrane,  thep/«  mater.  This  latter 
is  a  thin  vascular  sheath  applied  closely  to  the  cord  and  roots. 
The  space  between  the  dura  and  arachnoid  is  called  the  arachnoid 
cavity.  It  contains  a  very  little  cerebro-spinal  fluid.  That  between 
the  arachnoid  and  pia  is  called  the  subarachnoid  cavity ;  it  con- 
tains a  good  deal  of  cerebro-spinal  fluid.  Both  cavities  connect 
with  those  of  the  brain  and  probably  with  each  other.  The  dura 
has  a  mechanical  protective  function,  the  arachnoid  a  serous  and 
the  pia  a  vascular  function. 

The  spinal  cord  is  movable  in  its  canal  to  the  extent  of  one- 
half  to  one  inch. 

The  Nerve  Roots. — The  spinal  nerve  roots  are  covered  with 
the  pia  and  arachnoid.  They  pierce  the  dura  in  two  places  and 
unite  to  form  a  mixed  nerve.  The  dura  mater  is  prolonged  over 
the  nerves  as  they  pats  through   it,  forming  a  tubular  sheath. 


DISEASES   OF  THE   SPINAL  CORD. 


181 


The  anterior  roots  are  the  larger.     At  the  point  of  exit  of  the 
nerves  from  the  cord  a  sUght  depression  is  formed. 

The  Root  Ganglia.— On  each  posterior  root,  outside  the  dura, 


6b 


Ja 


Conus 
meduUaris. 


Filum 
terminale. 


Fig.  79.— Showing  the  Rel- 
ative Size  of  the  Different 
Parts  of  the  Cord  (after 
Allen). 


Fig.  80. — Transverse  Section  op  the 
Spine,  showing  the  relations  of  the  cord 
to  the  spinal  canal  (Keys  and  Retzius). 


Fig.  81.— Showing  the  Relations  of 
THE  Gray  Matter  to  the  White.  A, 
Anterior ;  L,  lateral  and  P,  posterior  col- 
umns; the  anterior  (a)  and  posterior  (2^) 
horns  and  intermediate  gray  matter. 


Fig.  82. —Showing  Further  Scbdi- 
visioNS  OF  the  White  Matter  and 
the  Location  of  the  Different  Cell 
Groups  in  the  Gray  Matter.  D,  P, 
Pyramidal  tracts;  CB,  col.  Burdach;  G, 
col.  Goll. 


is  a  posterior  spinal  ganglion.     The  ganglia  he  m  the  mterver- 
tebral  canal,  except  those  on  the  sacral  nerves. 

Fissu )<s—ThYo\iQho\it  the  Avhole  length  of  the  cord  there  are 
two  median  fissures,  called  the  anterior  and  posterior. 


lii'Z  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Col II  mns. —Theyv  fissures  .iikI  the  lines  formed  by  che  exit  of 
the  roots  divide  the  eord  into  four  columns— anterior,  posterior, 
and  two  lateral. 

T/te  Cninjxtsitiou  of  tfu'  Cord.— The  cord  is  composed  of  white 
and  f^ray  matter.  Tlie  wliite  matter  lies  outside  and  is  composed 
maiidv  of  nerve  fibres,  the  jj^ray  matter  mainly  of  nerve  cells. 
Each  has  also  neuroglia,  connective  tissue,  and  blood-vessels.  In 
the  ^ray  matter  is  a  central  canal  lined  with  epithelial  cells. 

'iht'unni  nidtttr  is  arranged,  as  shown  in  the  figures,  some- 
what in  the  shai)e  of  a  letter  H-  Its  different  parts  are  called  the 
anterior  and  posterior  horns  and  intermediate  gray.  At  certain 
levels  there  are  lateral  horns. 

The  gray  matter  changes  in  shape  at  different  levels  of  the 
cord.  It  is  greatest  in  amount  at  the  lumbo-sacral  junction 
(28.:3:3  sq.  nun.);  next  at  the  cervical  enlargement  (sixth  cervical) 
(17.:}2  sq.  nnn.).  It  increases  in  amount  relatively  to  the  white 
matter  from  above  downward  (Fig.  88). 

The  Commis.sure.— The  gray  matter  of  the  two  halves  of  the 
cord  is  connected  by  a  bridge  or  commissure.  The  anterior  part 
is  composed  chiefly  of  white  medullated  nerves,  and  is  called  the 
white  commissure!  The  posterior  is  composed  of  very  fine  nerve 
fibres,  mostly  medullated  collaterals,  called  the  gray  commissure. 
Between  the  two  is  the  central  canal,  and  surrounding  it  is  the 
central  gelatiuons  ^mbstance,  composed  of  neuroglia. 

The  posterior  horns  reach  to  the  periphery.  They  are  divided, 
beginning  from  without,  into. the  rim  zone  or  Lissauer  s  column, 
the  spongy  zone,  and  the  gelatinous  substance  of  Rolando.  The 
rim  zone  is  composed  of  very  fine  nerve  fibres;  the  spongy  zone 
and  gelatinous  substance  are  composed  chiefly  of  neuroglia  *  and 
small  nerve  cells. 

To  sum  up,  we  have  the  gray  matter — 

Arranged  in :  Composed  of : 

(  anterior,  a.  A  ground  substance    of    neu- 

1.  Horns:  -  lateral,  roglia  and  connective  tissue 

/  posterior.  forming  the  substantia  spon- 

2.  Intermediate  gray.  giosa. 

h.  Cell  groups :  internal,  anterior^ 
etc. 

c.  Plexuses    of  fine  nerve    fibres, 

e.g.,  in  the  rim  zone. 

d.  Masses  of  neuroglia : 

(1)  The  central  gelatinous  sub- 

stance. 

(2)  The  gelatinous  substance 

of   Rolando    and     the 
spongy  zone. 

e.  Blood  -  vessels    and    connective 

tissue. 

Now,  taking  up  some  of  these  factors  in  detail,  we  find  that 
{a)  The  ground  substance  of  the  gray  matter  is  made  up  of  a 
fine  meshwork  of  fibres  which  are  the  processes  of  neuroglia  cells 
and  of  nerve  cells.  Besides  this,  there  is  some  connective  tissue, 
and  there  are  prolongations  from  the  base  of  the  epithelial  cells 
lining  the  central  canal. 

*  Weigert's  new  staiu  seems  to  show  that  the  substance  is  not  neuroglia. 


DISEASES  OF  THE  SPINAL  CORD. 


183 


(b)  The  nerve  cells  are  arranged  in  groups  with  the  long  axis 
parallel  to  that  of  the  cord.     The  cells  are  surrounded  by  a  rich 
plexus  of  cell-processes  and  nerves,  as  well  as  by  the  supporting 
neuroglia  matrix,  a  little  con- 
nective tissue,  and  many  small 
blood-vessels.     The  cell  groujjs 
are   named    in    accordance 
mainly  with  their  position — in- 
ternal,   anterolateral,    lateral, 
median,    posterior    or    sensory 
spindle  cell,   and  the  cells  of 
Clark's  column  (Fig.  83). 

The  cells  are  arranged  in 
groups  which  overlap  each 
other.  Each  group  has  the 
special  duty  of  presiding  over 
certain  sets  of  muscles  or  other 
organs  which  have  a  common 
function. 

The  cells  of  the  anterior 
horns  are  large  in  size,  85  to 
100 /J-  (  yi^  to  2-i-o  in.);  they  are 
multipolar,  having  five  or  six 
processes,  one  of  which  is  an 
axis-cylinder  process.  The  cells 
in  the  central  parts  of  the  horn 
are  the  smaller;  the  cells  in  the 
lumbar  swelling  are  largest,  be- 
cause they  are  connected  with 
long  nerves.  The  cells  of  the 
cervical  swelling  are  next  in 
size.  The  cells  of  the  poste- 
rior horn  are  small  and  multi- 
polar. 

The  cells  of  Clark's  column 
are  bipolar,  30  to  GO//  (^^^  to  ^^^(y 

in.)   in  diameter,  and   are  ar-  [J  |^ 

ranged  with  their  long  diarne-  A     flfl  ^a 

ter  parallel  to  the  axis  of  the 
cord.  They  are  grouped  to- 
gether in  a  kind  of  nest  at  the 
inner  and  central  part  of  the 
posterior  horn  (see  Fig.  82). 
Clark's  column  is  most  distinct 
from  the  eighth  dorsal  to  the 
second  lumbar  nerves,  but  ex- 
tends up  as  far  as  the  last  cer- 
vical. An  analogous  group  of 
cells  is  found  at  the  level  of 
the  second  and  third  sacral 
nerves. 

The  spindle-cell  group  con- 
sists of  small  cells  lying  in  the 

intermediate  gray  matter  at  the  Fig.  83.— Showing  the  arrangement  of 
base  of  the  posterior  horns.  Cell  Groups  of  Anterior  Horns  and 
There  are  other  minor  groups  Intermediate  Gray  in  the  Upper  Half 
of  cells  which  it  is  not  neces-  op  the  Cord.  Sliowing  also  the  levels  to 
sary  to  describe  here.  which  each  group  extends. 


Cell  groups. 

antero-lateral     .  _ C\C\ 

lateral     ._...... 

uv 

U    h' 

A 

anterior    f\--A 

median 

A  /^ 

central   _ 

postero-lateral  ......     . .     .  U. 

median . , 

• 

central . 

inner C 

postero-lateral i .. 

lateral               (    . 

antero-lateral       _  .  _  .... 

median ...   . 

184 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  rchite  maiter  of  the  cord  is  composed  mainly  of  nerve 
fibres  running  in  a  supportino;  net-work  of  neurogjlia,  connective 
tissue,  and  hlood-vessels.  Surrounding  it,  and  lying  just  beneath 
the  pia  mater,  is  a  thin  laver  of  neuroglia  5  to  50  /^  (^^^  to  ^^  in-) 
thick.  The  nerve  fibres  are  medullated,  but  have  no  neurilemma, 
and  but  few,  if  anv,  nodes  of  Ranvier.  There  are  two  kinds .  the 
large  (81  to  20  //)  and  the  small  (2  to  3//  in  diameter).  The  small 
fibres  make  up  tbe  postero-internal  (GolPs)  column  entirely,  and 
are  numerous  in  the  deep  part  of  the  lateral  columns,  but  they 
are  fount!  in  aU  regicnis.  The  fibres  run  up  and  down  for  the  most 
part.     They  are  arranged  in  columns,  the  division  being  based 


Fig.  84.— Section  of  Spinal  Cord,  showing  complete  sulxlivision  of  white  col- 
umns into: 

TDPi",  Direct  pyramidal 
Anterior  j     tract, 
columns.  |  AFC,    Anterior    fimda-       Lateral 

(     mental  column.  columns. 


f  LFC,  Lateral  fundamental  column. 

I  LL,  Lateral  limiting  laj^er. 

J  CPyT.  Crossed  pyi'amidal  tract. 

1  CT.  Direct  cerebellar  tract. 

I  ALT,     Antero-lateral      ascending 

t     tract. 


Posterior  columns. 


{ Column  of  Goll. 

!  Column  of  Burdach. 

i  HZ,  Eiin  zone,  or  Lis-sauer's 

I,     column. 


f  ARZ,  Anterior  root  zone. 
J  3IRZ,  Middle  root  zone. 
1  OZ,  Oval  zone. 
tPRZ,  Posterior  root  zone. 


partly  on  anatomical,  partly  on  physiological,  and  j^artly  on  em- 
bryological  grr)unds. 

Anatomically  there  is  a  simple  and  natural  division,  which  Ave 
have  already  given,  into  the  anterior,  lateral,  and  posterior  col- 
umns, the  divisions  being  made  by  the  median  fissures  and  the 
roots  of  the  nerves  (see  Fig.  81). 

On  physiological  and  embryological  grounds  the  columns  are 
further  subsided  as  follows: 


The  anterior 
columns  are 
divided  into 


\  Direct  pyramidal  tract. 

"j  Anterior  fundamental  column. 


DISEASES   OF   THE   SPINAL  CORD.  185 

f  Lateral  fundamental  columns. 
ThP  latPral      I  Lateral  limiting  layers, 
ilie  lateral     ,  Q,.o,.gefi  pyramidal  tracts, 
columns  are    ^^  j^.^^^^  cerebellar  tracts. 

aiviaeci  inro    ^  ^j^^ero  -  lateral    ascending    tracts,     or     Gowers' 
1^     column. 

f  Postero-internal  column,  or  column  of  GoU. 
I  fBurdach's  column  is 

.        I  I        divided  into 

i  lie  posterior    ,  Postero-external  columns,  J     Anterior  root  zone, 
columns  are   -,     ^^.  column  of  Burdach.     1     Middle  root  zone, 
divided  into  I     Oval  root  zone. 

I  1^    Posterior  root  zone. 

[Rim  zone,  or  column  of  Lissauer. 

The  fibres  which  make  up  these  columns  are  of  two  kinds — 
long  or  projective,  short  or  associative. 

The  long  fibres  connect  the  dift'erent  levels  of  the  cord  with 
the  brain,  and  the  different  spinal  nerve  roots  Avith  nuclei  in  the 
upper  part  of  the  cord. 

The  short  or  associative  fibres  connect  different  levels  of  the 
cord  with  each  other,  and  also  connect  the  two  halves  of  the 
cord  at  the  same  levels. 

The  names  of  the  long-fibre  tracts  are  the  direct  and  crossed 
pyramidal,  the  direct  cerebellar,  the  antero-lateral  ascending,  and 
the  postero-internal  or  column  of  Goll. 

The  direct  j^yramidal  tract  lies  along  the  anterior  median 
fissure  and  extends  down  as  far  as  the  lower  part  of  the  dorsal 
cord.  Its  fibres  cross  over  in  the  anterior  commissure  at  various 
levels  and  connect  with  the  cells  of  the  anterior  horns. 

The  crossed  2:>]inimldal  tract  extends  dowai  the  whole  length  of 
the  cord  and  sends  its  fibres  to  the  anterior  horns  of  the  same  side. 

Both  of  the  above  tracts  are  continuations  of  the  anterior 
pyramids  or  motor  tracts  of  the  medulla.  These  pyramids  divide 
at  the  lower  end  of  the  medulla,  about  ninety  per  cent  of  fibres 
crossing  over  to  form  the  crossed  pyramidal  tract  and  ten  per 
cent  continuing  on  the  same  side.  Some  of  the  fibres  of  the 
crossed  pyramid  redecussate  (in  lower  animals)  and  enter  the  pyra- 
midal tract  of  the  side  on  which  thev  started  (Fig.  88,  PT). 

The  direct  cerebellar  tract  begins  at  the  level  of  the  first  lum- 
bar nerves.  Its  fibres  originate  in  the  vesicular  column  of  Clark. 
They  pass  up  to  the  cerebellum  and  go  chiefly  to  the  vermis. 
Most  of  them  then  cross  over  and  enter  the  red  nucleus  (Fig.  88). 

The  antero-lateral  ascending  column  extends  nearly  the  whole 
length  of  the  cord.  Its  fibres  come  from  the  posterior  commis- 
sure and  the  sensory  cells  of  the  opposite  posterior  cornu.  They 
pass  up  and  end  in  the  lateral  nucleus  (Fig.  88,  ALC). 

The  postero-internal  column,  or  column  of  Goll,  is  composed 
of  fibres  which,  originate  in  the  ganglia  of  the  posterior  roots, 
pass  inward,  and  without  crossing  ascend,  to  end  in  a  nucleus  at 
the  upper  limit  of  the  cord,  the  nucleus  of  GolPs  column  (postero- 
internal nucleus).  The  column  extends  the  whole  length  of  the 
cord.  It  is  very  small  in  the  sacral  region,  but  increases  in  size  as 
it  passes  up  (Fig.  88,  G).  .  1 1  +      i 

There  are  a  few  long  fibres  scattered  in  the  anterior  and  lateral 
ground  bundles.  They  degenerate  down  and  are  called  the  an- 
tero-lateral descending  tract. 


186 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  names  of  the  short-fibre  columns  are  the  anterior  and  the 
lateral  fundamental  columns,  the  lateral  limiting  layer,  and  the 
column  of  Burdach.  This  latter  column  contains  in  its  cervical 
part  some  long  fibres  which  end  in  a  nucleus  at  the  upper  limit 
of  the  cord,  the  postero-external  nucleus,  or  nucleus  of  the  col- 
umn of  Burdach  (Fig.  82,  CB). 

The  Relations  of  the  Different  Parts  of  the  Spinal 
Cord  to  the  Peripheral  Serves,  to  the  Brain,  and  with 
Each  Other.— I  will  begin  with  a  description  of  the  way  in 
which  the  anterior  and  posterior  nerve  roots  are  connected  to 


Fig.  85.— Shotvikg  the  Relations  of  the  Anterior  Roots  M,  W  to  the  An- 
terior HoRxs;  OF  the  Anterior  Horns  to  the  Crossed  Pyramidal  Tracts  and 
Posterior  Roots.  Slio-n-iug  also  the  relations  of  the  posterior  root  fibres :  T,  to 
column  of  Goll  and  Clark's  column;  P,  to  sensory  cells  and  posterior  column;  J,  to 
sensory  cells  and  antero-lateral  ascending  column  ;  R,  to  anterior  horns.  S,  Sensory 
root;  A,  muscle  sense;  P,  pain  and  temperature  sense;  T,  tactile  sense;  YR,  visceral 
and  reflex  fibres. 

the  cord ;  then  describe  the  mode  in  which  the  different  columns 
and  cell  groups  are  connected  with  each  other;  and  finally  I  will 
indicate  briefly  the  connections  of  the  cord  with  the  brain. 

The  anterior  nerve  roots  are  connected  directly  with  the  an- 
terior horn  cells,  of  which  they  are  processes. 

The  cells  of  the  anterior  horn  are  surrounded  by  two  sets  of 
"end-brushes,'' one  coming  from  the  pyramidal  tracts,  the  other 
from  the  posterior  horns  and  roots.  Thus  these  cells  are  in  rela- 
tion with  impulses  from  the  brain  and  from  the  periphery. 

The  i)osterior  nerm  roots  originate  chiefly  in  the  spinal  gan- 
glia. On  entering  the  cord  the  fibres  divide  like  a  T  and  pass  up 
and  down  for  one  or  two  inches.  They  then  enter  (1)  the  col- 
umn of  Groll,  (2)  the  anterior  or  posterior  commissure,  or  (3)  the 
posterior  horn.  They  all  send  off  collaterals,  and  terminate 
eventually  in  end-brushes  surrounding  nerve  cells. 

There  are  at  least  three  groups  of  nerve  fibres  which  enter  by 


DISEASES   OF  THE   SPINAL  CORD. 


187 


the  posterior  roots  and  make  different  connections  with  the  cell 
groups  or  columns ; 

1.  An  innermost  set.  These  pass  across  the  postero-external 
column  and  enter  the  median  or  Goll's  column,  which  they  as- 
cend, to  end  in  the  nucleus. 

2.  A  median  set.  These  pass  along  the  inner  side  of  the  pos- 
terior horn,  and  end  either  {a)  in  cells  of  the  deeper  part,  (5)  in 
the  spindle-shaped  cells,  or  (c)  go  to  the  anterior  horn ;  still  others 
(d)  cross  over  in  the  connnissure  to  enter  the  antero-lateral  tract. 


^^ 


Fig.  86.  Fig.  87. 

Fig.  86. — Showing  the  Connections  of  the  Anterior  and  Posterior  Roots 
AND  CoRNUA  WITH  Each  Other  (Cajal).  A,  Anterior  root;  B,  posterior  root;  «, 
collaterals;  d,  end-brushes. 

Fig.  87.  —  Showing  the  Association  or  Short-Fibre  System  op  the  Cord 
(Cajal).  a,  Anterior  cornua  cell;  b,  c,  d,  association  fibres;  e,  posterior  association 
fibres. 

3.  An  outer  set.  These  are  very  fine  fibres  which  enter  the 
tip  or  outer  part  of  the  posterior  horn,  and  then  run  up  and  down, 
forming  the  rim  zone.  They  eventually  connect  in  the  usual 
way  with  the  sensory  cells  of  the  posterior  horn  (see  Fig.  85,  A,  R). 

TJie  different  'parts  of  the  spiiial  cord  are  connected  by  the 
short  fibres  which  unite  different  levels  of  the  cord,  and  by  com- 
missural fibres  which  unite  the  different  halves  of  the  cord.     These 


188  DISEASES   OF  THE   NERVOUS   SYSTEM. 

s;hort  and  commissural  fibres  originate  in  groups  of  nerve  cells  ly- 
ing in  the  central  parts  of  the  gray  matter  and  called  associative 
nerve  cells.  They  are  small  and  multipolar.  Some  are  distrib- 
uted sparsely  in  the  white  columns.  Fibres  arise  from  them,  run 
in  the  commissures  and  short-fibre  tracts,  and  end  in  brushes 
which  put  the  fibres  in  relation  with  vai'ious  cell  groups  (Figs.  86, 
87). 

Physiology.— The  detailed  facts  regarding  the  functions  of 
the  spinal  cord  may  be  gotten  in  physiological  text-books.  I  shall 
give  only  those  bearing  more  or  less  directly  on  the  localization 
of  the  functions.  The  spinal  cord  is  a  conductor  and  centre  of 
nervous  action.  It  represents  the  lowest  evolutionary  level  of  the 
development  of  the  nervous  system.  Its  functions,  so  far  as  they 
are  independent,  are  stable  and  w^ell  organized,  but  of  a  mechan- 
ical and  relatively  simple  order. 

Functions  of  the  White  Col  anins.— The  white  matter  is  a  con- 
ductor of  nerve  impulses,  and  its  functions  are  relatively  simple. 
We  have  only  to  study  the  direction  and  kind  of  impulses  carried 
by  its  various  colunms.  The  direct  eind  c rossed 2->yramidal  tracts 
carry  motor  impulses  downward  from  the  brain.  A  few  fibres 
(two  to  ten  per  cent)  connect  with  muscles  of  the  same  side;  so 
that  in  hemiplegia  there  is  usually  some  weakness  on  the  healthy 
side.  These  tracts  normally  exercise  a  continual  inhibitory  in- 
fluence on  the  motor  cells  of  the  anterior  horns;  so  that  when  de- 
stroyed there  develop  spasmodic  conditions  of  the  paralyzed  part. 

The  anterior  ground  bundle,  lateral  ground  bundle,  and  the 
lateral  limiting  laijer  have  the  function  of  associating  different 
levels  of  the  cord  and  of  connecting  it  also  with  nuclei  in  the 
medulla  and  centres  in  the  cerebellum. 

The  columns  of  Goll  conduct  special  sensations  from  the  mus- 
cles, articulations,  and  tendonous  sheaths  via  the  root  on  the  same 
side.  When  diseased,  there  is  a  loss  of  the  sense  of  position  of  the 
limbs,  of  the  power  of  estimating  weights,  and  of  co-ordination 
of  muscular  effort  (ataxia).     The  fibres  cross  over  in  the  medulla. 

The  columns  of  Burdach  conduct  to  a  certain  extent  tactile 
sensations  coming  in  from  the  opposite  posterior  root.  They  also 
contain  many  associative  fibres,  connecting  different  levels.  Pain- 
sense  fibres  and  excito-refiex  fibres  from  the  posterior  roots  run 
through  these  columns  to  reach  the  commissure  or  the  anterior 
horns ;  othei-  fibres  run  through  it  to  Clark's  column  and  to  the 
column  of  (roll.  Hence  it  is  a  pathAvay  for  all  kinds  of  afferent  im- 
pulses. When  diseased, there  may  be  pain,  anaesthesia,  ataxia,  and 
loss  of  reflexes.     The  fil^j-es  cross  over  at  once  to  the  opposite  side. 

The  antero-lateral  ascend i)ig  tract  conducts  sensations  of  pain 
and  temperature,  comini>-  in  from  the  opposite  side,  through  the 
anterior  and  posterior  conmiissure. 

There  are  considerable  variations  in  the  paths  of  conduction 
of  tactile  tempei-ature  and  pain  sensations,  and  their  exact  posi- 
tion is  not  positively  known.  In  transverse  lesions  of  the  cord 
these  tracts  do  not  genei-ate  u])ward  so  completelv  or  uniformly 
as  do  secondary  dej^enerations  of  otlier  long-fibre  tracts.  Hence 
they  probably  receive  some  interruptions  in  their  course. 

Automatic  Centres.— The  nerves  and  cells  of  the  cord  are  ar- 
ranged in  complex  groups  which  preside  over  certain  functions 
or  respond    in  a  definite    wav  to   certain   stimuli.     These    are 


DISEASES   OF  THE   SPINAL  CORD. 


18^ 


called  the  spinal  automatic  centres, 
secretory,  vasomotor,  genital,  vesical 
tant  pai-ts  of  these  centres  lie  deep 
in  the  gray  matter  on  either  side  of 
the  central  canal,  but  nearer  the 
base  of  the  posterior  horns.  Lesions 
of  the  white  matter,  or  of  the  an- 
terior or  posterior  horns,  do  not 
directly  afiect  them. 

The  cillo-spinal  centre  reaches 
from  the  seventh  cervical  to  the 
second  dorsal  segment,  inclusive. 
Its  stinuilation  causes  the  pupils  to 
contract. 

The  genital  centres,  including 
those  for  erection  and  ejaculation, 
reach  from  the  first  to  the  third 
sacral  segment,  inclusive. 

The  bladder  and  rectal  centres 
are  in  the  fourth  and  fifth  sacral 
segments,  extending  up  and  down 
a  short  distance,  the  bladder  being 
perhaps  a  little  lowt  r. 

The  spinal  vasomotor  ceiitres  ex- 
tend from  the  second  dorsal  to  the 
second  lumbar  segments. 

The  vaso-dilator  nerves  pass  out 
by  the  anterior,  the  constrictor  by 
the  posterior,  root  (Gaskiil). 

The  gray  matter  contsiiuii  chiefly 
cell  groups  which  act  as  centres 
and  distributors  of  nerve  impulses. 
In  the  anterior  horns  the  cells  have 
a  motor  and  trophic  function.  The 
larger  cells  are  at  the  outer  parts 
of  the  horn  and  send  fibres  to  the 
larger  skeletal  muscles.  The  more 
central  cells  are  connected  with 
small  muscles  and  those  having 
more  delicate  functions  and  adjust- 
ments. In  the  still  more  central  and 
intermediate  parts,  also,  are  sepa- 
rate trophic  cells  for  the  muscles, 
bones  and  joints,  and  cell  groups 
which  preside  over  vasomotor  and 
secretory  functions.  Among  these 
groups  are  the  spindle-shaped  cells, 
which  send  fibres  to  the  vaso-con- 
strictors  (Gaskill),  through  the  ante- 
rior (Hill)  and  perhaps  posterior 
roots  (Gaskill).  The  cells  of  Clark's 
column  receive  fibres  from  the  vis- 
cera and  blood-vessels.  Impulses 
pass  to  these  cells  and  thence  to  the 
direct  cerebellar  tract  and  cerebel- 
lum. Their  function  is  to  conduct 
impulses  from  the  viscera  relating 
to  equilibrium  and  sense  of  posi- 


They  are  the  cillo-spinal, 
and   rectal.      The  impor- 


FiG.  88.— Showing  the  Relation 
OF  THE  Arrangement  of  the  Gray 
Matter,  Cell  Groups,  and  White 
Columns  at  Four  Different  Lev- 
els. Namely,  mid-cervical,  mid- 
dorsal,  lower  dorsal,  and  upper 
sacral.    (Drawn  from  specimens.) 


190 


DISEASES   OF  THE   XERVOUS   SYSTEM. 


tion.  They  are  analogrous  to  the  fibres  of  the  column  of  Goll. 
Accord ingr  to  Gaskill,  Clark's  column  is  a  centre  for  the  vaso-dila- 
tors.     This  is  unlikely. 

The  rells  of  the  posterior  horns  are  sensory  in  function  and 
are  connected  with  the  tactile,  pain,  temperature,  and  reflex 
fibres  of  the  posterior  roots. 

The  trophic  centres  for  the  joints,  hones,  and  skin  apparently 
lie  in  the  posterior  horns.     Their  fibres  pass  out  by  the  posterior 

I'oots.  ^,  .      .  .        -, 

Topography  and  Lor-aUzation.—The  neurologist  and  surgeon 
need  to  know,  for  purposes  of  diagnosis : 

1.  The  relation  of  the  special  nerve  roots,  at  their  point  of 
origin,  to  the  spinous  processes.  This  is  shown  in  the  figure 
(p.  150).  In  general  it  will  be  seen  that  the  different  pairs  of  nerve 
roots  arise  opposite  the  spinous  process  of  a  vertebra  one  or  two 
segments  above  those  between  which  it  makes  its  exit.  Thus 
the  sixth  cervical  originates  opposite  the  fourth  cervical  spine, 
the  sixth  dorsal  between  the  third  and  fourth  dorsal  spines,  the 
first  lumbar  between  the  eleventh  and  twelfth  dorsal  spines. 
There  is  considerable  variation  in  these  relations,  as  the  diagram 
from  Reid  shows  (Fig.  72). 

2.  The  next  points  desired  are  the  special  function  of  each 
pair  of  nerve  roots  anterior  and  posterior,  and  the  level  of  the 
various  centres  in  the  cord.  This  is  shown  in  the  following  table, 
based  on  that  originally  devised  by  Starr,  modified  by  Mills 
and  myself  from  personal  experiments  and  the  clinical  and  path- 
ological observations  of  Thorburn  and  others. 

Localization  of  the  Fttnctions  of  the  Segments  of  the  Spinal  Cord. 


Segment. 

Muscles. 

Reflex  and  Centres. 

Sensation. 

First    t-ervi- 

Rectus  laterales. 

cal. 

Rectus  capitis. 
Aiiticus  and  posticus. 
Sternohyoid. 
Sternn-thyroid. 

Second  tind 

Sternomastoid. 

Hyioocliondrium    (f). 

Back  of  head  to  vertex 

third   cer- 

Trapezius. 

Sudden    inspiration 

and  neck.     (Occipi- 

vical. 

Scaleni  and  neck. 

i:)roduced    b}'    sud- 

talis major,  occipi- 

Oino-hyoid. 

den     pressure     be- 

talis minor,  auricu- 

Diaphragm. 

neath  the  lower  bor- 

laris magnus.  super- 

der  of  ribs. 

ficialis  colli,  and  su- 
praclavicular.) 

Fourtli   cer- 

Diaphragm. 

Pupillary  (fourth  cer- 

Neck. 

vical. 

Deltoid. 

vical  to  second  dor- 

Shoulder,  anterior 

Biceps. 

sal).    Dilatation  of 

surface. 

Coraco-brachialis. 

the  pupil  produced 

Outer    arm.     (Supra- 

Supinator longus. 

by  irritation  of 

clavicular,    circum- 

Rhomboid. 

neck. 

flex,  external  mus- 

Supra-  and   infra-spi- 

culo-curaneous,  cu- 

natus. 

taneous.) 

Fifth   cervi- 

Deltoid. 

Satpular  (fifth  cervi- 

Back of  shoulder  and 

cal. 

Biceps. 

cal  to  first  dorsal). 

arm. 

Coraco-brachialis. 

Irritation    of     skin 

Outer  side  of  arm  and 

Brachialis  amicus. 

over    the     scapula 

forearm     to      the 

Supinator  longus. 

produces     contrac- 

wrist.      ( Supracla- 

Supinator brevis. 

tion     or     scapular 

vicular,  circumflex. 

Deep   muscles  of 

muscles. 

external  cutaneous, 

shoulder-blade. 

Stipimdor   longus. 

internal  cutaneous. 

Rhomboid. 

Tapping  the  tendon 

posterior  spinal 
branches.) 

Teres  minor. 

of    the    supinator 

Pectoralis  (clavicular 

longus     produces 

part). 

flexion  of  forearm. 

Serratus  magnus. 

DISEASES   OF   THE   SPINAL  CORD. 


191 


Segment. 

Muscles. 

Reflex  and  Centres. 

Sensation. 

Sixth  cervi- 

Deltoid. 

Tricex>s  (fifth  to  sixth 

Outer  side  and  front 

cal. 

Biceps. 
Brachialis  anticus. 

cervical).    Tapping 

of  forearm. 

elbow    tendon    pro- 

Back of  hand,  radial 

Subscapulai-. 

duces  extension  of 

distribution. 

Pectoralis  (clavicular 

forearm. 

(Chiefly    external 

part). 

Posterior  ivrist  (sixth 

cutaneous,  internal 

Serratus  magnus. 

to  eighth  cervical). 

cutaneous,  radial.) 

Triceps. 

Tapping  tendons 

Pronators. 

causes  extension  of 

Rhomboid. 

hand. 

Latissimus  dorsi. 

Seventh  cer- 

Triceps (long  head). 

Anterior  ivrist    (sev- 

Radial distribution  in 

vical. 

Extensors     of     wrist 

enth  to  eighth  cer- 

the hand. 

and  fingers 

vical)  .    Tapping  an- 

Median distribution  in 

Pronators  of  wrist. 

terior        tendons 

the  palm,  thumb,  in- 

Flexors of  wrist. 

causes    flexion     of 

dex,    and  one-half 

Subscapular. 

wrist. 

middle  finger. 

Pectoralis  (costal 

Palmar  (seventh  cer- 

(External cutane- 

part). 

vical  to  first  dorsal). 

ous,    internal  cuta- 

Serratus magnus. 

Stroking      palm 

neous,  radial,  medi- 

Latissimus dorsi. 

causes     closure    of 

an,  posterior  spinal 

Teres  major. 

fingers. 

bi'anches.) 

Eighth   cer- 
vical. 

Triceps  (long  head). 
Flexors  of  wrist  and 

Ulnar  area  of  hand, 

back,  and  palm,  in- 

fingers. 

ner  border  of  fore- 

Intrinsic   hand    mus- 

arm.    (Internal  cu- 

cles. 

taneous,  ulnar.) 

First  dorsal. 

Extensors  of  thumb. 

Chiefly  inner  side  of 

Intrinsic    hand    mus- 

forearm and  arm  to 

cles. 

near  the  axilla. 

Thenar  and  hypothe- 

(Chiefly     internal 

nar  muscles. 

cutaneous  and  nerve 
of  Wrisberg  or  les- 
ser internal  cutane- 
ous.) 

Second  dor- 

Inner side  of  arm  near 

sal. 

and  in  axilla.  (In- 
tereosto-humeral.) 

Second  to 

Muscles  of  back  and 

Epigastric  (fourth  to 

Skin  of  chest  and  ab- 

twelfth 

abdomen. 

seventh    dorsal). 

domen,   in    bands 

dorsal. 

Erectores  spinee. 

Tickling  mammary 

running  around  and 

region    causes     re- 

downward, corre- 

traction of  the  epi- 

sponding  to  spinal 

gastrium. 

.  nerves. 

Abdominal    (seventh 

Upper  gluteal  region. 

to  eleventh  dorsal). 

(Intercostals       and 

Stroking  side  of  ab- 

•dorsal    posterior 

domen    causes    re- 

nerves.) 

traction  of  belly. 

Vasomotor      centres. 

Second    dorsal  to 

second  lumbar. 

First  lum- 

None. 

Cremasteric  (first  to 

Skin    over  groin  and 

bar. 

third       lumbar). 

front    of    scrotum. 

Stroking  inner  thigh 

(  1 1  i  o  -hypogastric, 

causes  retraction  of 
scrotum. 
Patellar.  Striking  pa- 

ilioinguinal.) 

Second  lum- 

Vastus internus. 

Outer  side  and  upper 

bar. 

tellar  tendon  causes 

front  of  thigh.  Lum- 

extension of  leg. 

bar  region.  ((Jenito- 
crural.  external  cu- 
taneous.) 

Third  lum- 

Sartorius;   adductors 

Front  and  outer  side 

bar. 

of  thigh. 

of  thigh.    Inner  side 

Flexors  of  thigh. 

of  leg  and  foot. 

Fourth  lum- 

Extensors of  knee. 

Gluteal     (fourth     to 

Inner  side   of    thigh. 

bar. 

Abductors  of  thigh. 

fifth  lumbar).  Strok- 

leg,  and  foot.     (In- 

ing  buttock  causes 

ternal      cutaneous, 

dimpling  in  fold  of 

long  saphenous,  ob- 

buttock. 

turator.; 

192 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


Segment. 


Fifth  lum 
bar. 


3Iuscles. 


Outward  rotators. 
I  Flexors  of  knee. 
I  Flexors  of  ankle. 

Peronei. 

Extensors  of  toes. 


First    and   I  Calf  muscles, 
st-cond  sa-     Glutei. 


cral. 


Peronei. 

Extensors  of  ankle. 
Small  muscles  of  foot. 


Third,  fourth.      Perineal, 
and  fifth  !>a-     3Iuscles    of    bladder, 
cral.  rectum,  and  exter- 

nal genitals. 


Reflex  and  Centres. 


Achilles  tendon.  Over- 
extension causes 
rapid  flexion  of  an- 
kle, called  ankle 
clonus. 


Plantar  (fifth  lumbar 
to  second  sacral). 
Tickling  sole  ot  foot 
causes  flexion  of 
toes  and  retraction 
of  leg. 

Genital  centre. 
Vesical  centre. 
Anal  centre. 


Sensation. 


Back  of  thigh  and 
outer  side  of  leg 
and  ankle  ;  sole  ; 
dorsum  of  foot. 
(External  popliteal, 
external  saphenous, 
musculo-cutaneous, 
plantar.) 

Back  of  buttock  and 
thigh,  side  of  leg 
and  ankle  :  sole ; 
dorsum  of  foot. 


Circumanal  region, 
anus,  rectum,  penis, 
urethra, vagina,  per- 
ineum. 

(Small  sciatic,  pu- 
dic.  inferior  hemor- 
rhoidal, inferior  pu- 
dendal.) 


The  blood  supply  of  the  spinal  cord  is  a  subject  of 
great  practical  importance;  and  as  our  knowledg-e  of  it  has  lately 
been  increased,  I  shall  present  the  matter  here  in  some  detail. 

The  spinal  cord  is  supplied  with  blood  by  branches  from  the 
vertebrals,  ascending  cervical,  and  superior  intercostal  arteries 
above,  and  by  the  dorsal  intercostal,  lumbar,  and  sacral  arteries 
below.  These  send  off  small  branches  which  enter  the  spinal 
canal  through  the  foramen  magnum  above  and  the  interverte- 
bral foramina  at  the  sides;  they  pierce  the  dura  mater  and  are 
distributed  on  the  pia  mater  and  in  the  cord.  The  arteries  that 
thus  supply  the  cord  are  these : 


Primary  Arteries. 

Origin  from 

Ending  in 

Anterior  spinal 

Posterior  spinal 

Lateral  spinal 

Vertebral  (from  subclav.). 

Vertebral. 

Vertebral. 

Ascending  cervical  (from  sub- 
clav.). 

Superior  intercostal  (from  sub- 
clav.). 

Thoracic  intercostal  (from 
aorta). 

Lumbar  (aorta). 

Lateral  sacral  (from  int. 
iliac). 

Anterior  median  spinal  ar- 
tery. 

Lateral  spiual 

Lateral  spinal 

Lateral  spinal 

Lateral  spinal  

Anterior  and  posterior  spi- 
nal root  arteries. 

Anterior  and  posterior  spi- 
nal r<  lot  arteries. 

Anterior  and  posterior  spi- 
nal root  arteries. 

Anterior  and  posterior  spi- 
nal root  artei-ies. 

The  anterior  spinal  arteries  are  branches  of  the  vertebrals. 
They  unite  to  form  the  anterior  median  artery,  which  runs  down 
the  whole  length  of  tlie  cord,  receiving  re-enforcements  from  the 
lateral  arteries  (Fig.  89).  The  anterior  spinal  arteries  themselves 
nourish  only  a  few  upper  segments'  of  the  cord.  The  anterior 
median  artery  is  not,  as  has  been  taught,  a  true  prolongation  of 
the  anterior  spinals,  but  is  really  made  up  bv  the  lateral  .'^pinals. 
In  other  words,  the  vertebral  artery  tlirough  its  branches  only 
nourishes  the  upper  cervical  region  of  the  cord.     The  posterior 


DISEASES   OF   THE   SPINAL   CORD. 


193 


MU 


^^ 


/ 


"^ 


\ 


^ 


Fig.  89.— The  Spinal  Cord,  Anterior  Surface,  showing  the  nerve  roots,  root 
arteries,  and  anterior  plexus  (Kadyi). 
13 


104  DISEASES   OF  THE  NERVOUS   SYSTEM. 

spinal  arteries  are  smaller  than  the  anterior  and  unite  on  the 
posterior  surface  of  the  cord.  They  do  not  continue  down  as  a 
posterior  median  arter}'— there  is  no  such  artery ;  but  they  help 
to  form  two  plexuses  on  the  jjostero-lateral  surfaces  of  the  cord. 

The  hiteral  spinal  arteries  are  derived  from  branches  of  the 
subclavian  artery  as  far  down  as  the  second  dorsal  root ;  below 
this  point  by  the'  thoracic  and  abdominal  aorta  and  the  internal 
iliac.  It  is  an  interesting?  fact  that  at  or  a  little  below  the  point 
where  the  blood  supply  changes  from  the  subclavian  above  the 
heart  to  the  aorta  below,  pathological  disturbances  frequently 
occur  (transverse  myelitis). 

Root  Arteries. — The  lateral  spinal  arteries,  after  they  enter  the 
spinal  canal,  are  called  the  root  arteries.  They  pierce  the  dura 
mater  and  pass,  some  along  the  posterior  and  some  along  the  an- 
terior roots,  to  the  cord.  There  are  about  eight  anterior  root 
arteries  (five  to  ten)  and  about  sixteen  posterior  root  arteries  (see 
Figs.  89,  90).  The  anterior  arteries  are  twice  as  large  (one  milli- 
metre in  diameter)  and  one-half  as  numerous  as  the  posterior. 
The  root  arteries  of  the  cervical  region  are  rather  the  more  nu- 
merous.    There  is  a  large  and  constant  anterior  root  artery  in  the 


trpl-    "^'P 


Fig.  90.— Arterial  Supply  of  Cord,  r.a.,  Anterior  root  arteiy  ;  r.p.,  posterior 
root  arterj-;  tr.a.,  anterior  plexus*  tr.p.  and  tr.pl.,  posterior  and  lateral  plexuses 
(Kadyi). 

dorso-lumbar  region.  The  last  two  lumbar,  the  five  sacral  nerves, 
and  the  unpaired  coccygeal  nerve  when  it  exists  are  accompanied 
by  small  root  arteries  which  do  not  reach  up  to  the  cord  itself. 
The  lower  part  of  the  spinal  cord  is  supplied  by  large  root  arte- 
ries from  the  lateral  spinal  arteries.  Hence  the'  theory  of  Moxon 
that  the  circulation  here  is  feeble  is  not  supported  by  Kadyi's  in- 
vestigations. 

The  Fte.vuses.— The  anterior  root  arteries  pass  to  the  anterior 
median  fissure,  and  then  divide,  partly  to  form  the  anterior  me- 
dian artery  and  partly  to  form  a  rich  plexus  between  the  ante- 
rior roots :  this  is  called  the  antei'ior  arterial  plexus.  Tne  poste- 
rior root  arteries  subdivide  before  they  reach  the  cord,  and  send 
twigs  to  its  lateral  and  posterior  surfaces  which  form  the  postero- 
lateral arterial  plexus.  The  posterior  root  arteries  do  not  anas- 
tomose to  any  extent  with  each  other  or  form  a  posterior  spinal 
artery,  as  is  done  by  the  anterior  root  arteries.  There  are  there- 
fore three  relatively  independent  arterial  plexuses:  The  ante- 
rior plexus;  the  two  postero-lateral  plexuses. 

Veins.— The  veins  of  the  spinal  canal  outside  the  dura  mater 
have  valves,  those  within  it  have  none.  The  veins  reach  the  pia 
mater  and  cord  by  passing  along  the  nerve  roots.  Hence  we 
have  anterior  and  posterior  root  veins,  corresponding  to  the  root 


DISEASES   OF  THE   SPINAL  CORD.  195 

arteries,  but  more  numerous,  there  being  a  total  of  forty  or  fifty. 
The  anterior  root  veins  are  more  numerous  than  the  posterior,  but 
smaller  (twenty-five  to  twenty).  The  veins  are  a  little  larger 
than  the  arteries,  the  anterior  veins  being  one-half  to  one  milli- 
metre, the  posterior  one  and  one-half  to  two  millimetres,  in  diam- 
eter. 

Thus  we  see  that  the  posterior  surface  of  the  cord  has  more 
and  smaller  arteries,  fewer  but  larger  veins.  The  posterior  sur- 
face is  on  the  whole  more  richly  supplied  with  veins,  the  anterior 
surface  with  arteries.     The  lateral  surfaces  are  the  least  vascular. 


Number. 

Size. 

Anterior  root  arteries ■ 

Anterior  root  veins    

5  to  10. 
25  to  30. 

16. 
20  to  25. 

1     nana. 

Yj,  to  1     mm. 

1^  mm. 

11^  to  2     mm. 

Vessels  of  tJie  Cord  Substance. — The  cord  is  supplid  by  (1)  cen- 
tral arteries  which  are  branches  of  the  anterior  median,  and  by 
(2)  peripheral  arteries  which  come  from  the  plexuses  on  the  pia 
mater.  These  two  systems  have  been  called  also  the  centrifugal 
and  centripedal  respectively.  They  are  not  absolutely  indepen- 
dent, but  are  in  a  good  measure  so.  The  central  arteries  nourish 
chiefly  the  gray  matter,  the  peripheral  arteries  the  white.  Both 
systems  are  made  of  "  end  arteries,"  i.e.,  they  do  not  anastomose 
with  each  other.  Neither  the  central  nor  peripheral  arteries  are 
distributed  in  accordance  with  anatomical  relations  or  physiolog- 
ical functions.  Each  cell  group,  for  example,  has  a  vascular  sup- 
ply from  several  sources. 

The  central  arteries  are  given  off  from  the  branches  of  the  an- 
terior median  at  the  bottom  of  the  median  fissure  and  number 
about  two  hundred,  each  spinal  segment  having  six  or  seven. 
The  accompanying  central  veins  are  small  and  their  total  ca- 
pacity is  less  than  that  of  the  arteries,  so  that  the  central  arterial 
pressure  must  be  high,  on  account  of  the  poor  venous  outlet 
(Kadyi).     Some  of  the  blood  escapes  by  the  peripheral  veins. 

The  peripheral  arteries  pass  into  the  spinal  cord  for  the  most 
part  along  the  various  connective-tissue  septa.  There  they  branch 
and  supply  chiefly  the  white  matter.  They  supply  the  apex  and 
some  of  tlie  deeper  substance  of  the  posterior  horns  and  Clark's 
columns.  The  arteries  of  the  posterior  septum  are  the  largest 
and  most  numerous,  often  reaching  to  the  gray  commissure.  The 
peripheral  arteries  are  smaller  than  the  corresponding  veins  (.04 
to  .2  mm.).  The  relation  is  just  the  reverse,  therefore,  of  that  of 
the  central  arteries  and  veins.  The  peripheral  arteries  are  small, 
and  after  passing  into  the  cord  branch  into  minute  vessels  which 
pass  up  and  down  and  soon  become  capillaries.  The  central 
arteries,  on  the  other  hand,  continue  large,  and  run  up  and  down 
some  distance  before  they  are  subdivided  into  capillaries. 

To  sum  up :  the  arteries  predominate  in  total  capacity  in  the 
anterior  plexus  and  central  arteries.  The  veins  in  the  posterior 
plexuses  and  peripheral  veins.  The  central  arteries  are  larger 
and  longer  than  the  peripheral.  Hence  the  blood  circulates  more 
quickly  and  under  greater  pressure  in  the  central  gray  of  the 
cord.  Conditions  of  enfeebled  circulation  would  affect  the  pos- 
terior columns  and  roots  more  than  the  anterior  and  central  parts 
of  the  cord. 


CHAPTER  XL 

THE  DISEASES  OF  THE  SPINAL  CORD. 

There  are  about  thirty  diseases  which  may  be  classified  as 
belonging  to  the  spinal  cord.  Most  of  these  are  organic  in  char- 
acter and  come  under  the  head  of  inflammatory  and  degenerative 
or  system  diseases.  Functional  disorders  referable  to  the  cord 
alone  are  rare ;  while  of  organic  diseases,  those  that  result  from 
injury  and  inflammation  are  the  most  common. 

Miologi/.— The  causes  of  spinal-cord  diseases  can  nearly  all  be 
formulated  under  the  heads  of  injury,  exposure,  poisons,  auto- 
toxiemise,  infections,  and  excessive  functioning.  Persons  of  mid- 
dle life  are  the  most  predisposed,  while  heredity  does  not  play 
an  important  part. 

Symptoms. — The  symptoms  of  all  disorders  of  the  nervous 
centres  can  be  included  under  the  heads  of  those  of  irritation, 
depression,  and  perversion.  The  princii3al  irritative  symptoms  in 
spinal-cord  disease  are  pains  and  parsesthesise  of  the  back  and 
limbs,  hypersesthesia  and  feelings  of  constriction  around  the  waist, 
rigidity,  spasms,  exaggerated  reflexes,  and  irritability  of  the  vis- 
ceral and  vascular  functions.  The  principal  symptoms  of  depres- 
sion and  destruction  are  anaesthesia,  ataxia,  paralysis,  wasting, 
and  loss  of  power  over  visceral  centres.  The  common  form  of 
paralysis  in  spinal-cord  disease  is  paraplegia,  in  brain  disease 
hemiplegia,  in  multiple  neuritis  quadruplegia.  Symptoms  of  irri- 
tation and  depression  often  accompany  each  other.  The  more 
superficial  and  meningeal  the  disease,  the  more  are  the  symp- 
toms irritative;  the  more  central  and  myelonic  the  trouble,  the 
less  the  irritation  and  the  more  the  paralysis  and  visceral  dis- 
turbance. Thus  meningitis,  meningeal  tumors,  and  hemorrhages 
are  extremely  j^ainful ;  w^hile  central  myelitis  is  almost  painless. 

Pa^/io/o.^.y.— Inflammations  of  the  meninges  of  the  cord  are 
not  rare ;  the  opposite  is  true  of  X3rimary  inflammations  of  the 
cord  itself.  As  will  be  shown  later,  most  of  the  diseases  that  used 
to  be  called  chronic  myelitis  are  secondary  to  injuries  and  soft- 
enings. Degenerative  diseases  of  the  cord,  which  include  such 
affections  as  locomotor  ataxia  and  progressive  muscular  atrophy, 
used  to  be  called  "  system  diseases  "  because  they  affected  certain 
long-fibre  tracts  or  systems  of  cell  groups.     The  name  implies  re- 


DISEASES   OF   THE   SPINAL   CORD.  197 

strictions  which  are  not  justified  in  fact,  and  it  can  only  be  re- 
tained as  a  matter  of  convenience.  Secondary  degenerations 
alone  are  aways  systemic.  The  cord  is  relatively  free  from  ab- 
scesses hemorrhages,  and  tumors. 

Diagnosis. — In  making  a  diagnosis  of  spinal-cord  diseases,  one 
is  most  helped  by  a  thorough  knowledge  of  the  cord  functions. 
In  no  part  of  the  economy  do  physiology  and  anatomy  point  out 
more  clearly  the  path  to  the  clinician. 

Prognosis.— The  spinal-cord  tissue  once  destroyed  can  never 
be  renewed,  or  only  to  a  limited  extent,  and  that  as  regards  the 
nerve  fibres,  not  the  cells.  It  has  considerable  power  of  adjusting 
itself  to  damage;  but,  on  the  other  hand,  serious  injury  is  likely 
to  extend  by  the  process  of  secondary  degeneration.  Functional 
diseases,  vascular  and  nutritive  disturbances,  of  the  cord  can 
never  be  so  severe  or  chronic  as  to  exclude  the  possibility  of  re- 
covery. 

The  special  diseases  of  the  spinal  cord  are  the  following : 

1.  Malformations:  Myelocele,  meningo-myelocele  (spina  bifida), 
meningocele,  heterojjia,  amyelia,  micromyelia,  macromyelia, 
double  cord. 

2.  Vascular  Disorders :  Anaemia,  hypersemia,  hemorrhage,  en- 
darteritis with  aneurism,  embolism  or  thrombosis,  oedema.  Sec- 
ondary to  these  conditions  are  softenings  and  sclerosis. 

3.  Iiiflamniations :  Meningitis,  myelitis,  abscess.  Secondarily, 
softenings,  sclerosis. 

4.  Degenerations :  Primary :  locomotor  ataxia,  combined  scler- 
oses, hereditary  scleroses,  progressive  muscular  atrophy,  and 
allied  types. 

5.  Tiiherculo.ns :  Miliary  and  solitary. 

6.  Syphilis :  Gumma,  meningo-myelitis,  vascular  disease. 

7.  Tumors. 

8.  Functional  and  toxic  disorders. 

MALFORMATIONS. 
Spina  Bifida  (Rachischisis  Posterior). 

Spina  bifida  is  a  congenital  hernia  of  the  spinal  membranes,  and 
sometimes  of  the  cord,  through  a  cleft  in  the  vertebra  caused  by 
absence  of  the  vertebral  arches.  It  is  really  a  malformation  of 
the  vertebral  canal  rather  than  of  the  cord. 

Etiology. — The  condition  is  not  very  rare,  about  1  child  in  1,200 
(French  statistics)  being  affected.  It  is  often  associated  with  hy- 
drocephalus or  with  some  other  defect  in  development,  such  as 
ventral  hernia,  imperforate  anus  or  pharynx.  Hereditary  influ- 
ence is  sometimes  a  factor.     It  is  a  true  developmental  defect, 


198 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


and  is  not  clue  to  a  primary  dropsy  of  the  cord,  as  was  once 
taught. 

Forms.— There  are  three  varieties  described: 

1.  Spinal  meningocele  is  a  condition  in  which  the  spinal  mem- 
branes alone  protrude  into  the  sac. 

2.  Spinal  meningo-myelocele  is  a  form  in  which  the  mem- 
branes and  cord  both  protrude. 

3.  Syringo-myelocele  (hydrorachis  interna)  is  a  form  in  which 
the  fluid  is  in  the  central  spinal  canal,  and  the  inner  lining  of  the 
sac  is  formed  by  the  meninges  and  thinned-out  spinal  cord. 

Anatomy. — The  first  two  forms  are  the  most  common  and  are 
called  hydrorachis  externa.  The  fluid  here  lies  in  the  subarach- 
noid sac,  and  hence  the  wall  of  the  protruding  cyst  is  lined  with 


a  b  ca 


a  bca 


Fig.  91.- 


-Meningocele.      Meningo-Myelocele.      Syringo-Myelocele. 
a,  Vertebral  walls;  b,  cord;  c,  membranes. 


the  dura  and  arachnoid.  The  nerves  and  cord  protrude  into  the 
sac  in  two-thirds  of  the  cases  (forming  a  meningo-myelocele).  but 
in  some  of  these  only  a  few  nerves  are  found.  These  structures, 
when  present  in  the  sac,  lie  on  \t^  posterior  and  median  surface., 
sometimes  causing  a  depression  there.  The  tumor  contains  cer- 
ebro-spinal  fluid,  and  occasionally  connective  tissue  and  fat 
(Fig.Ol). 

Symptoms. — Spinal  bifida  occurs  almost  always  in  the  lumbar 
and  sacral  region,  the  reason  being  that  the  lamina  here  are  the 
last  to  solidify.  Usually  but  two  or  three  vertebrie  are  involved. 
The  tumor  varies  in  size  from  3  cm.  (one  inch)  to  15  cm.  (six 
inches)  in  diameter  and  may  have  a  broad  base  or  be  peduncu- 
lated. The  outer  skin  is  often  glossy,  or  tough,  thickened,  or 
ulcerated. 

Children  with  spina  bifida  are  usually  feeble,  badly  nourished, 
and  poorly  developed    mentally.      Paraplegia    occurs    in    half 


DISEASES   OF   THE   SPINAL  CORD. 


199 


the  cases,  sometimes  with  anaesthesia  and  involvement  of  the 
sphincters.     Tahpes  occurs  quite  often. 

The  prognosis  is  grave.     Most  cases  die  unless  treatment  is 
applied,  and  even  then  the  prospect  is  not  very  good. 

The  diagnosis  is  easy.  It  is  generally  only  necessary  to  ex- 
clude congenital  tumors  which  happen  to  be  located  in  the 
lumbo-sacral  region.  The  most  important  question  to  decide  is 
whether  the  cord  and  nerves  are  present  in  the  sac.  This  may 
be  assumed  as  probable  if  there  is  much  paraplegia,  anaesthesia, 
and  sphincter  trouble.  The  introduc- 
tion of  an  insulated  needle  connected 
with  an  electric  battery  may  be  tried. 

The  treatment  is  strictly  surgical. 
At  present,  injections  of  Morton's  fluid 
(iodine,  gr.  x. ;  potas.  iodid.,  gr.  xxx. ; 
glycerin,  1  i.  Dose,  3  i.)  have  been  most 
successful.  These  injections  should  be 
made  in  the  lateral  portion  of  the  sac, 
and  the  child  should  be  kept  on  the 
back.  Puncture  and  withdrawal  of 
fluid  with  compression  is  not  a  justifi- 
able operation  The  ligature  or  open- 
ing and  excision  of  the  sac  are  danger- 
ous, especially  if,  as  is  often  the  case, 
part  of  the  cord  and  nerves  lie  in  the 
sac.  In  recent  years,  surgical  results 
have  been  more  favorable  and  warrant 
serious  consideration.  No  surgical 
treatment  should  be  attempted,  however,  until  two  or  three 
months  after  birth. 


Fig.  92.— Spina  Bifida. 


Heteropia  is  a  rare  malformation  in  which  masses  of  gray 
matter  are  found  in  abnormal  situations.  A  false  heteropia  may 
be  caused  (Van  Giessen)  by  manipulation  of  the  cord  in  its  removal 
after  death.  The  displaced  masses  consist  of  nerve  cells  or  neu- 
roglia. 

Amyelia  or  absence  of  the  spinal  cord  can  only  exist  when 
the  brain  is  absent;  but  absence  of  the  brain  may  occur  without 
absence  of  the  cord.  In  amyelia  the  spinal  nerves  are  usually 
present.     Amyelic  monsters  cannot  live. 

Double  cord  is  a  very  rare  defect  and  involves  only  part  of 
the  cord,  except  in  cases  in  which  there  is  a  double  vertebral 
canal. 

Double  central  canal  is  not  rare.  It  usually  involves 
only  a  part  of  the  cord.     The  two  canals  are  side  by  side. 

Asymmetry  of  the  cord,  usually  due  to  abnormality  in  the 
course  of  the  pyramidal  tracts,  is  not  extremely  rare. 

Splitting  of  the  cord  and  defects  in  development  at  spe- 
cial levels  are  occasionally  observed. 

MiCROMYELY  is  a  condition  in  which  the  spinal  cord  is  abnor- 


200  DISEASES  OF  THE  NERVOUS  SYSTEM. 

iiially  short  or  small  in  size,  and  is  not  a  very  rare  anomaly.  The 
normal  adult  cord  has  a  diameter  in  its  various  parts  of  6  to  9 
mm.  (dorsal),  8  to  11  mm.  (upper  cervical),  15  mm.  (cervical  swell- 
ing)^ and  12  mm.  (lumbar). 


Spinal  Hemorrhage  (Spinal  Apoplexy). 

This  general  name  may  be  given  to  (1)  spinal  meningeal  hem- 
orrhage or  hiematorhachis,  and  (2)  hemorrhage  into  the  cord  sub- 
stance, or  hematomyelia. 

1.  Spinal  meningeal  hemorrhage  is  far  the  most  com- 
mon form.  It  may  be  outside  or  inside  of  the  dura,  the  former 
being  rather  oftener  seen. 

Etiology.— It  occurs  in  newly  born  children  and  in  adults,  and 
is  more  common  in  men  than  in  women.  Injuries,  falls,  fractures 
of  the  spine  are  the  most  frequent  exciting  causes.  Severe  con- 
vulsions from  epilepsy,  eclampsia,  tetanus,  chorea,  or  strychnia 
may  be  a  cause,  also  severe  muscular  exertion.  Purpura  and  the 
blood  states  following  malignant  infectious  fevers,  bursting  of  an 
aortic  or  vertebral  aneurism  and  cerebro-spinal  meningitis  are 
rare  causes. 

Symptoms.— \n  small  hemorrhages  there  may  be  no  symptoms. 
In  large  effusions  there  are  sudden,  very  severe  pains  in  the  back, 
extending  into  the  limbs,  numbness,  tingling,  hyperesthesia,  and 
muscular  spasm,  especially  of  the  back  muscles.  Later  there  may 
be  weakness  or  paralysis  and  anaesthesia,  with  disorder  of  the  vis- 
ceral centres.  The  symptoms  reach  their  height  usually  in  a  few 
hours.  Then  amelioration  may  occur,  followed  by  slow  recovery 
or  with  symptoms  of  chronic  meningitis.  Rarely  death  occurs 
early  from  exhaustion. 

Diagnosis. — A  history  of  injury,  child-birth,  sudden  onset  of 
attack,  with  symptoms  of  pain  and  irritation  which  rather  rap- 
idly subside,  point  to  extra-dural  hemorrhage.  In  haematomyelia 
there  is  less  pain  and  irritation,  but  more  profound  paralysis  and 
anaesthesia.  The  same  is  true  of  crush  of  the  cord  from  fracture 
or  dislocation.  In  tetanus  there  is  a  slower  development  of  the 
symptoms,  and  trismus  is  present. 

The  prognosis  is  grave  in  severe  cases;  but  if  the  patient  sur- 
vives three  or  four  days,  the  prospect  of  partial  or  nearly  complete 
recovery  is  good. 

The  treatment  is  perfect  rest  in  bed  and  the  administration 
of  remedies  to  move  the  bowels  and  relieve  pain;  leeches  and 
other  local  applications  are  of  doubtful  value.  It  is  of  no  use  to 
give  styptics  except  in  purpura,  when  mineral  acids  or  chloride 
of  calcium  may  be  tried.  Later,  one  may  give  iodide  and  mercury 
and  use  blisters  to  the  back. 


DISEASES   OF   THE   SPINAL  CORD.  201 

Hemorrhage  into  the  Substance  of  the  Cord  (Hjema- 
TOM.YEijiA).—Btiology.—The  condition  is  not  very  rare.  It  may- 
be primary  from  disease  of  the  blood-vessels  or  purpura  hsemor- 
rhagica;  or  it  may  be  secondary  to  myelitis  and  tumors.  Pri- 
mary hemorrhage  occurs  sometimes  in  infancy,  but  usually  in 
males  between  the  twentieth  and  fortieth  year.  Injuries,  over- 
exertion, exposure,  excessive  coitus  ((iowers),  and  convulsions  are 
causes. 

The  symptoms  develop  rapidly,  with  at  first  feelings  of  numb- 
ness or  weakness  for  one  or  two  hours  or  longer.  Then  there  is 
a  sudden  paraplegia,  with  anaesthesia  or  ataxia  or  both.  The 
sphincters  may  be  paralyzed  ;  the  urine  has  to  be  drawn.  The 
reflexes  may  be  abolished  at  first,  but  soon  return  and  become 
exaggerated.  There  is  considerable  pain  in  the  back.  If  the 
lesion  is  high  up,  the  arms  and  thorax  are  involved.  The  acute 
symptoms  begin  usually  to  subside  at  the  end  of  seven  to  ten 
days  and  the  disease  takes  the  character  of  a  chronic  myelitis. 
If  improvement  does  not  occur,  evidences  of  acute  myelitis  appear 
and  the  patient  dies. 

Pathology. — The  vessels  involved  are  the  central  arteries, 
which  supply  the  gray  matter  and  are  under  relatively  high  pres- 
sure. The  rupture  of  the  vessel,  when  due  to  disease,  is  caused  by 
a  fatty  degeneration  of  the  coats ;  miliary  aneurisms,  such  as  are 
found  in  the  brain,  rarely  develop  in  the  cord.  Hemorrhage 
often  precedes  or  begins  a  myelitis,  of  which  it  may  be  the  cause 
or  the  result.  The  clot  may  be  absorbed,  leaving  a  cavity  as  in 
the  brain ;  or  the  broken-down  tissue  may  become  the  centre  of 
a  myelitic  focus.  The  hemorrhage  is  usually  single,  but  there 
may  be  several.  Multiple  capillary  hemorrhages  occur,  but  usu- 
ally only  from  asphyxia  and  convulsions.  It  is  possible  that 
some  of  the  cases  of  disseminated  myelitis  occurring  after  infec- 
tious fevers  start  from  small  hemorrhages. 

Diagnosis. — The  points  to  be  noted  are  the  sudden  onset  with- 
out long  premonitory  symptoms,  and  the  absence  of  fever,  fol- 
lowed later  by  gradual  improvement.  The  disease  is  often  mis- 
taken for  acute  primary  myelitis,  which  does  in  fact  often  follow 
it.  Meningeal  hemorrhage  is  more  painful,  and  there  is  less 
paralysis,  more  spasm,  and  a  more  complete  recovery  later. 

Prognosis. — This  is  often  serious  as  regards  life,  and  always 
serious  as  regards  health.  It  depends  on  the  extent  and  seat  of 
the  hemorrhages.  Dorsal  hemorrhages  are  more  favorable,  cer- 
vical the  least. 

Treatment.— Kh^o\\xte  rest,  ice-bags  to  the  spine,  and  small 
doses  of  aconite  given  early  are  all  that  can  be  done,  except 
the  use  of  symptomatic  remedies.  Treatment  must  be  applied 
at  once.    The  late  treatment  is  the  same  as  that  for  myelitis. 


202  DISEASES   OF  THE   NERVOUS   SYSTEM. 


The  Caissox  Disease  (Diver's  Paralysis). 

Etiology.— The  caisson  disease  is  the  name  g:iven  to  a  more  or 
less  complete  paraplegia  which  occurs  in  persons  who  work  in 
caissons  or  diving-bells,  and  which  is  brought  about  by  the  sud- 
den return  from  a  condensed  air  to  the  normal  atmosphere.  Per- 
sons employed  in  caissons  or  bells  work  usually  under  a  pressure 
of  from  one  to  four  atmospheres,  which  means  a  pressure  of  from 
fifteen  to  fifty  pounds  to  the  square  inch.  Accidents  rarely  if  ever 
occur  when  the  pressure  is  not  over  one  atmosphere,  and  they 
are  also  rare  if  the  person  has  not  been  subjected  to  the  pressure 
for  at  least  an  hour.  DiiTerent  persons  vary  in  susceptibility  to 
the  effects  of  this  change  in  the  atmospheric  pressure,  and  those 
unused  to  the  work  are  more  liable  to  be  attacked. 

The  symptoms  set  in  usually  very  soon  after  the  pafient  has 
come  out  from  the  caisson,  but  they  may  be  delayed  for  half  an 
hour  or  more.  They  consist  of  intense  neuralgic  pains  in  the 
lower  extremities,  often  affecting  especially  the  joints.  There  is 
at  the  same  time  epigastric  pain.  Nausea  and  vomiting  and  weak- 
ness in  the  lower  limbs,  amounting  in  some  cases  to  absolute  paral- 
ysis, very  soon  appear.  There  may  be  headache,  dizziness,  and 
sometimes  even  coma.  If  the  paralysis  is  considerable,  it  is  usu- 
ally accompanied  with  anaesthesia.  Disturbances  in  the  sphinc- 
ters, with  retention  of  urine  and  constipation,  may  also  be  present. 
The  symptoms  vary  very  much  in  severity,  from  pain,  weakness 
in  the  legs,  and  nausea  up  to  frightful  neuralgic  attacks  and 
complete  paralysis,  motor  and  sensory.  The  upper  limbs  are 
rarely  affected.  In  a  few  instances  hemiplegia,  however,  has 
been  observed.  The  disease  lasts  from  a  few  hours  up  to  several 
weeks.  Death  occurs  in  some  of  the  very  severe  cases.  The 
symptoms  having  reached  their  climax  gradually  ameliorate, 
and  a  complete  cure  is  not  infrequent.  In  some  instances,  how- 
ever, the  patient  is  left  with  a  permanent  paraplegia  and  the  or- 
dinary symptoms  of  a  transverse  myelitis. 

Pathology.— V^hew  the  patient  is  under  atmospheric  pressure 
in  the  caisson,  the  blood  is  driven  from  the  surface  of  the  body, 
and  .the  internal  viscera,  including  the  brain  and  cord,  are  con- 
gested. The  sudden  change  from  the  abnormal  to  normal  pres- 
sure produces  a  rapid  flow  of  blood  from  the  internal  organs  to 
the  periphery.  The  viscera  not  inclosed  in  bony  cavities  are  en- 
abled to  relieve  themselves  of  this  cohgestion  without  much  harm, 
but  the  circulation  in  the  brain  and  spinal  cord  is  less  elastic; 
that  in  the  spinal  cord  being  less  even  than  that  in  the  brain. 
The  result  is  that  congestions  and  small  hemorrhages  ensue,  pro- 
ducing a  destruction  of  the  nerve  tissue.     In  other  cases  there 


DISEASES   OF  THE   SPINAL  CORD.  203 

seems  to  be  a  blocking  up  of  some  of  the  small  vessels,  with  con- 
sequent softening  of  different  portions  of  the  cord  and  to  a  less 
extent  of  the  brain.  It  is  supposed  that  one  element  in  produc- 
ing the  morbid  phenomena  is  the  escape  of  oxygen  and  carbonic- 
acid  gas  from  the  blood  into  the  tissues  or  into  the  blood-vessels. 
This  mechanism,  however,  has  not  been  absolutely  proven.  It 
will  be  seen,  however,  that  on  the  w^hole  the  sudden  change  in 
atmospheric  pressure  leads  to  vascular  disturbances  with  rupture 
or  obliteration  of  blood-vessels,  with  consequent  destruction  and 
necrosis  of  tissue.  Following  this  is  a  reactive  inflammation  pro- 
ducing the  phenomena  of  an  ordinary  acute  myelitis. 

The  treatment  is  largely  prophylactic.  The  workmen  engaged 
in  the  occupation  should  be  carefully  selected  and  should  accus- 
tom themselves  to  their  work.  They  should  spend  a  longer  time 
in  coming  out  of  the  caisson.  If  symptoms  supervene,  it  is  rec- 
ommended that  they  be  put  back  under  a  slight  atmospheric 
pressure  at  once  until  these  symptoms  disappear.  When  the 
disease  has  developed,  it  can  only  be  treated  by  symptomatic 
remedies.  The  patient  should  be  kept  quiet  and  given,  if  nec- 
essary, hypodermics  of  morphine.  Dr.  A.  H.  Smith  recommends 
the  use  of  ergot.  Later  on,  the  various  neuralgic  and  paralytic 
symptoms  may  be  treated  on  the  same  principles  as  those  em- 
13loyed  in  myelitis. 

Spinal  Hyperemia,  Acute  and  Chronic. 

^^io?0(7v/.— Acute  spinal  hypersemia  is  produced  by  sexual  ex- 
cesses, violent  physical  exertion,  suppression  of  menstrual  dis- 
charges, and  certain  poisons  like  strychnine.  It  occurs  also  in 
the  first  stage  of  acute  inflammatory  diseases. 

Chronic  spinal  hypersemia  is,  so  far  as  is  absolutely  known, 
a  very  rare  condition.  Chronic  hypersemia  of  the  membranes 
may  be  the  residuum  of  a  meningitis  or  of  injury,  and  these  are 
probably  the  most  common  causes.  As  to  the  causes  of  the 
chronic  hypersemia  of  the  cord  substance  itself  independent  of 
other  diseases,  we  can  say  nothing  definitely. 

The  symptoms  of  acute  spinal  hypersemia  are  feelings  of  heavi- 
ness and  weight  in  the  limbs  and  around  the  loins,  numbness, 
creeping  sensations  and  actual  neuralgic  pains,  weakness  of  the 
lower  limbs,  with  twitchings  of  the  muscles.  There  may  be  also 
some  disturbance  in  the  sphincters",  though  of  this  one  can  speak 
less  certainly.  The  symptoms  are  nearly  always  confined  chiefly 
to  the  lower  limbs.  The  statement  that  they  are  increased  by 
lying  on  the  back  and  ameliorated  by  lying  on  the  face  is  not 
always  true,  since  posture,  unless  greatly  prolonged,  influences 
but  very  slightly,  if  at  all,  the  circulation  in  the  spinal  cord. 


204  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  symptoms  of  chronic  spinal  hypersemia,  when  this  hyper- 
semia  involves  the  meninges  chiefly,  are  probably  somewhat  iden- 
tical with  those  of  spinal  irritation.  They  will  be  described  under 
that  head. 

Pathology. —The  circulation  of  the  blood  in  the  spinal  cord,  as 
has  been  shown  in  the  article  on  anatomy,  is  one  which  it  is  diflS- 
cult  to  disturb;  but  which,  once  disturbed,  is  rather  slow  in  being 
brought  back  to  its  normal  condition.  Thus  violent  activity  of 
the  heart  and  great  increase  in  the  arterial  pressure,  and  the  op- 
posite conditions  of  weakened  heart  and  lowered  arterial  tension, 
appear  but  little  to  modify  the  spinal  functions.  Hence  it  is  un- 
likely that  the  large  number  of  clinical  symptoms  that  have  at 
times  been  attributed  to  hypersemia  of  the  spinal  cord,  or  rather 
to  disturbances  in  the  circulation  of  the  spinal  cord,  have  really 
been  due  to  that  cause. 

Treatment. — The  treatment  of  spinal  hyperemia  consists  in 
the  application  of  cups  to  the  back,  quiet  in  the  horizontal  posi- 
tion, preferably  upon  the  side  or  face,  ice  and  counter-irritants 
to  the  spine,  morphine  and  bromides  internally.  In  the  more 
chronic  cases  muriate  of  ammonia,  iodide  of  potassium,  and  the 
galvanic  current  may  be  used.  The  use  of  ergot,  which  has  been 
recommended,  in  my  experience  has  been  found  of  little  or  no 
value. 

Spinal  Anemia. 

Even  less  is  known  in  regard  to  the  etiology  and  symptoma- 
tology of  spinal  antemia  than  of  spinal  hypersemia.  Undoubtedly 
severe  hemorrhages  or  diarrhoeal  discharges,  and  an  aortic  ob- 
struction which  cuts  off  the  circulation  of  the  blood  from  the 
spinal  cord,  will  produce  a  spinal  anaemia,  and  when  this  is  se- 
vere the  functions  of  the  cord  are  nearly  abolished.  But  prac- 
tically we  do  not  know  of  any  causes  which  produce  an  acute  or 
chronic  aniemia  leading  to  serious  and  prolonged  disturbances 
in  the  spinal  functions,  aside  from  diseases  of  the  arteries  of  the 
spinal  cord  themselves  such  as  occur  in  advanced  life.  In  the 
most  profound  anaemias  which  must  affect  equally  the  spinal  cord 
with  other  organs  very  little  special  disturbance  of  this  organ  can 
be  discovered.  Here,  too,  the  supposed  test  of  improvement  on  ly- 
ing on  the  back  is,  in  the  writer's  ojjinion,  a  fallacious  one.  It  has 
been  customary  to  associate  with  spinal  anaemia  a  class  of  symp- 
toms characterized  by  pains  in  the  back  of  the  nature  of  spinal 
irritation,  weakness  of  the  legs  amounting  to  paraplegia— a  type 
of  symptoms  that  has  been  called  spinal  concussion,  but  it  is  im- 
possible in  the  present  stage  of  science  to  say  that  a  spinal  anaemia 
actually  underlies  and  causes  this  condition. 


DISEASES   OF  THE   SPINAL  CORD.  205 


INFLAMMATION  OF  THE  SPINAL  MEMBRANES  (SPINAL 
MENINGITIS). 

The  meningeal  inflammations  are : 

External  meningitis.  ^  a<¥    +•      j.u    i  x 

Internal  menin|itis.  \  ^ffectmg  the  dura  mater. 

Leptomeningitis.  [  Affecting  the  pia  mater. 

Hypertrophic  pachymeningitis.     [  Affecting  both  membranes. 


External  Meningitis,  Pachymeningitis  Externa 
("  Compression  Myelitis  ''). 

Etiology. — The  disease  is  rare,  and  always  occurs  secondarily 
to  some  other  morbid  process.  This  process  is  in  most  cases 
tuberculosis  and  caries  of  the  vertebrae.  Other  causes  are  sup- 
purative inflammation  in  the  neighborhood  of  the  vertebrae,  psoas 
abscess,  purulent  pleurisy,  peritonitis,  and  puerperal  pyaemia. 
When  the  disease  arises  from  inflammations  in  the  visceral  cavi- 
ties, it  is  thought  to  be  caused  by  an  ascending  neuritis. 

The  Symptoms. — The  symptoms  are  those  of  irritation  of  the 
motor  and  sensory  roots ;  later,  compression  of  them  and  of  the 
spinal  cord,  local  pain  in  the  back,  radiating  pains,  tenderness, 
hypersesthesia,  twitching,  paresis,  paraplegia,  exaggeration  of  re- 
flexes, and  involvement  of  the  sphincters.  Anaesthesia  occurs  in 
severe  forms. 

The  disease,  when  chronic,  may  extend  to  the  other  membrane 
and  cord,  causing  what  is  termed  "  compression  myelitis." 

Pathological  Anatomy. — The  inflammation,  if  acute,  is  gener- 
ally a  fibro-purulent  one,  this  being  the  form  usually  caused  by 
vertebral  caries.  The  dura  mater  is  covered  by  a  layer  of  case- 
ous, semi-solid  matter,  often  very  thick  and  most  extensive  pos- 
teriorly. It  involves  the  dura  vertically  for  several  inches.  In 
chronic  forms  the  deposit  is  made  up  of  connective  tissue  and 
the  cord  is  compressed.  In  purely  suppurative  forms  the  cellu- 
lar tissue  outside  the  dura  is  infiltrated  with  pus  throughout  a 
great  part  of  the  canal. 

The  diagnosis  is  based  on  the  presence  of  the  primary  local 
disease,  the  kyphosis,  the  radiating  pains,  and  tenderness,  and  by 
the  combination  of  motor  and  sensory  irritation  and  paralysis. 

The  pro.(/?z-06Z5  is  generally  bad  because  the  original  disease  is 
a  serious  one. 

The  treatment  consists  in  attention  to  the  local  caries  or  in- 
flammatory focus.     It  is  therefore  purely  surgical. 


Internal  Meningitis,  Pachymeningitis  Interna, 
Hemorrhagic  and  Hypertrophic. 

Inflammation  of  the  inner  surface  of  the  dura  mater  occurs  in 
two  forms— the  hemorrhagic  and  the  hypertrophic.  As  the  latter 
IS  generally  but  a  sequel  of  the  former,  I  shall  describe  the  two  to- 
gether under  the  head  of  hypertrophic  pachymeningitis. 


20G  DISEASES  OF  THE  NERVOUS   SYSTEM. 

Etiohtgy.— The  disease  occurs  almost  always  in  adult  life.  A 
few  cases  have  been  reported  in  children  ( Gibney).  It  usually 
affects  males.  Syphilis,  alcoholism,  exposure,  and  trauma  are  ex- 
citing: causes. 

jSi/t)ipto /US. —The  disease  begins  gradually  with  symptoms  of 
irritation  (irritative  stage).  The  patient  suffers  from  pain  and 
stiffness  in  the  neck.  The  pains  radiate  up  to  the  occiput  and 
down  the  back;  numbness,  prickling,  and  pain  are  felt  in  the 
arms,  more  in  one  than  the  other.  The  pains  exacerbate  and  are 
worse  at  night.  Stiffness  and  cramjjs  may  affect  the  arms. 
Nausea  and  vomiting  sometimes  occur. 

After  five  or  six  months,  symptoms  of  paralysis  appear  (para- 
lytic stage).  The  ai-ms  are  first  affected.  They  become  weak, 
atrophy  occurs,  associated  with  contractures  and  rigidity.  There 
is  still  pain,  and  in  addition  anaesthesia,  hyperjesthesia,  and 
trophic  changes.  Later,  paraplegia,  with  rigidity,  exaggerated 
reflexes,  and  spinal  epilepsy,  develop.  The  patient  becomes 
weaker,  and  finally  dies  of  exhaustion  or  from  some  intercurrent 
trouble.  The  disease  sometimes  takes  what  is  called  the  periph- 
eral type.  Then  the  symiDtoms  are  more  localized  in  the  extrem- 
ities. Usually  it  is  of  the  cervical  type  and  presents  symptoms  as 
described  above.  In  either  form  the  disease  is  a  chronic  and 
painful  one. 

Pathology.— The  disease  starts  as  a  hemorrhage  upon  the  sur- 
face of  the  dura.  This  leads  to  a  chronic  inflammatory  process, 
new  hemorrhages  occur,  and  a  fresh  inflammatory  deposit  is  made 
until  the  cord  is  finally  encircled  and  compressed  by  a  dense  con- 
nective-tissue mass,  which  involves  the  pia  and  to  some  extent 
the  cord  substance.  The  process  is  analogous  to  that  of  cerebral 
pachymeningitis  hemorrhagica.  The  cervical  region  is  usually 
attacked. 

Prognosis. — A  few  cases  have  been  reported  practically  cured. 
More  cases  eventually  die.  Sometimes,  however,  the  disease 
comes  to  a  standstill  for  a  long  time. 

Diagnosis.— This  must  be  made  from  tumor,  myelitis,  Pott's 
disease,  wry-neck,  and  progressive  muscular  atrophy.  The  his- 
tory of  injury,  the  slow  progressive  course,  and  the  localization  of 
the  symptoms,  their  bilateral  character  and  the  pain,  give  the 
most  help.     It  is  not  always  possible  to  exclude  a  tumor. 

Treatinent. — The  not  rare  syphilitic  origin  of  the  disease  must 
be  borne  in  mind.  Counter-irritants,  electricity,  hydrotherapy, 
and  symptomatic  remedies  for  the  pain  and  spasms  are  indicated. 
It  is  possible  that  surgery  may  help  these  cases. 


Acute  Spiral  Leptomexixgitis  (Ixflammatio^^  of  the 
Pia  Mater  of  the  Spiral  Cord). 

Etiology. — This  is  a  rare  disease,  occurring  alone,  but  is  com- 
mon in  connection  with  disease  of  the  cerebral  pia  mater. 

Children  are  oftenest  affected,  and  among  adults,  males.  Al- 
coholism predisposes  to  it.  The  disease  is  always  secondary  to 
an  infection  or  a  traumatism.  The  infections  are  tubercle,  syph- 
ilis, typhoid  fever,  and  sei)tic{emia.  Extension  of  inflammation 
from  neighboring  parts  and  surgical  operations   are  occasional 


DISEASES   OF   THE   SPINAL  CORD.  207 

causes.  The  cases  attributed  to  rheumatism,  exposure,  insola- 
tion, are  in  reaUty  due  to  some  infection,  and  the  virus  of  cerebro- 
spinal fever  sometimes  attacks  the  cord  alone. 

Symptoms.— The  disease  begins  with  pain  in  the  back,  radiat- 
ing along  the  nerves.  There  is  usually  a  chill  and  some  fever. 
The  pulse  may  be  fast  or  slow.  The  pain  increases,  and  is  ac- 
companied with  dorsal  tenderness  and  rigidity  of  the  muscles  of 
the  back,  amounting  sometimes  to  opisthotonus.  The  skin  is 
very  hyperaesthetic  and  the  reflexes  are  at  first  increased.  There 
is  constipation,  and  sometimes  retention  of  urine.  After  a  time 
symptoms  of  paralysis  come  on,  with  anaesthesia  and  retention 
of  urine.  The  patient  becomes  weaker,  bed-sores  may  form,  and 
death  from  exhaustion  follow.  The  disease  lasts  from  a  few  days 
to  several  weeks. 

The  dominant  symptoms  in  the  first  stage  are  those  of  irrita- 
tion, viz. : 

Pain  in  back  and  along  the  nerves,  hypersesthesia,  muscular 
spasm.     In  the  second  stage,  paralysis,  atrophy,  and  anaesthesia. 

In  the  tuhei'cular  form  of  meningitis  the  symptoms  come  on 
more  slowly.  In  septic  meningitis  the  symptoms  are  of  the  severe 
and  typical  kind  described.  In  meningitis  from  other  infections 
the  symptoms  are  not  so  severe  as  a  rule. 

Pathological  Anatomy^ — Acute  leptomeningitis  shows  a  some- 
what different  exudate  according  to  the  nature  of  the  infecting 
micro-organisms.  The  common  form  is  the  suppurative  exudate 
which  may  be  due  to  the  streptococcus  pyogenes  and  other  pyo- 
genic micro-organisms,  and  to  the  pneumococcus.  The  purulent 
matter  is  usually  distributed  along  the  whole  length  of  the  cord, 
but  more  posteriorly  and  often  more  in  its  lower  portion.  It  may 
also  be  localized  chiefly  at  certain  levels.  The  spinal  fluid  is  in- 
creased in  amount.  The  arachnoid,  the  inner  surface  of  the  dura, 
and  the  tissue  of  the  cord  itself  are  usually  involved.  If  the  dis- 
ease lasts  several  weeks,  the  purulent  matter  is  absorbed  in  part 
and  an  increase  in  connective  tissue  takes  place,  binding  the 
dura,  arachnoid,  and  pia  to  the  cord.  The  nerve  roots  are  sur- 
rounded and  compressed  by  the  inflammatory  product. 

In  tubercular  meningitis  there  is  less  exudate.  It  is  more  of  a 
fibrinous  character,  and  grayish  in  appearance.  Tubercle  gran- 
ulations are  seen  distributed  over  the  pia,  arachnoid,  and  inner 
surface  of  the  dura.  Simple  exudative  meningitis  rarely  occurs. 
The  inflammatory  process  often  ends  in  a  production  of  new 
connective  tissue  and  sometimes  the  establishment  of  a  chronic 
leptomeningitis. 

The  diagnosis  must  be  made  from  myelitis,  tetanus,  rabies, 
rheumatism  of  the  dorsal  muscles,  gonorrhoea!  rheumatism,  and 
strychnine-poisoning.     In  myelitis  there  is  relatively  little  pain 


206  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  much  paralysis;  in  tetanus  there  is  trismus,  fever  is  absent^ 
and  there  is  a  history  of  trauma. 

Tubercular  meningitis  comes  on  more  slowly,  is  rarely  spinal 
alone,  and  there  may  be  evidence  of  local  tuberculosis  elsewhere. 

The  prognosis  is  not  good,  but  is  especially  bad  in  tubercular 
meningitis  and  in  cases  with  high  fever,  severe  pains,  and  early 
paralysis.  Chronic  meningitis  sometimes  remains  after  the  acute 
symptoms  subside. 

Treatment.— This,  consists  first  in  perfect  rest  and  quiet; 
leeches  should  be  applied  along  the  spine,  then  hot  poultices  or 
ice-bags;  opium  is  to  be  given  lor  relief  of  pain;  mercurial 
purges  and  small  doses  of  iodide  of  potassium  or  sulphate  of 
magnesium  may  be  given  at  short  intervals.  Later,  blisters  and 
counter-irritation  and  lukewarm  baths  are  indicated. 

Chroxic  Leptomexixgitis  axd  Mexixgomyelitis. 

Etiology. — This  disease,  which  used  to  be  often  diagnosticated, 
is  now  believed  to  be  rare,  and  always  secondary  to  an  acute  pro- 
cess or  to  syiDhilis  and  jjerhaps  chronic  alcoholism.  It  occurs 
oftenest  in  adults  and  in  males.  Trauma,  and  especially  concus- 
sion of  the  spine,  used  to  be  thought  a  frequent  cause,  but  in 
most  of  such  cases  the  trouble  is  simply, a  hypera^mia  or  else  neu- 
ralgic and  functional. 

The  symj^tonis  gradually  develop  after  an  acute  meningitis  or 
an  injury,  and  they  are  the  same  in  character  as  those  of  the 
acute  process.  There  is  pain  in  the  back,  increased  on  movement 
and  radiating  about  the  trunk  and  down  the  limbs ;  tenderness 
along  the  spine,  stiffness  of  the  back,  twitching  and  spasms  in 
the  limbs  with  some  weakness,  and  later  some  paralysis,  wasting, 
and  anaesthesia,  with  weakness  of  the  bladder.  These  jparalytic 
symptoms,  if  severe,  however,  mark  an  invasion  of  the  spinal  cord. 
Cutaneous  eruptions,  such  as  herpes,  may  appear.  The  symp- 
toms run  an  irregular  course,  with  periods  of  improvement. 
They  always  become  less  when  the  patient  rests. 

Pathological  Anatomy.— The  inflammation  consists  of  a  pro- 
liferation of  connective  tissue  (productive  inflammation  of  Dela- 
field).  The  result  is  a  thickening  and  opacity  of  the  pia  mater 
and  arachnoid.  The  dura  mater  may  be  involved,  but  only  in 
severe  cases.  The  process  may  invade  the  spinal  cord,  causing  an 
"  annular  ^'  or  ringlike  sclerosis,  from  which  the  disease  extends 
into  the  cord  in  wedge-shape  masses  at  various  parts,  causing 
eventually  an  involvement  of  fibre-systems  and  secondary  degen- 
erations up  and  down.  This  somewhat  rare  terminal  condition 
is  called  meningo-myelitis. 

The  diagnosis  must  be  made  from  suinal  irritation,  locomo- 


DISEASES   OF   THE   SPINAL   CORD.  209 

tor  ataxia,  myelitis,  vertebral  caries,  and  torticollis.  In  spinal 
irritation  there  are  not  the  rigidity,  severe  radiating  pains,  twitch- 
ings,  atrophy,  or  paralysis;  and  neurasthenia  or  hysteria  exists. 
In  locomotor  ataxia  the  knee  jerk  is  lost,  there  is  ataxia,  and  there 
is  little  paralysis,  nor  is  there  local  tenderness  over  the  spine. 

In  vertebral  caries  the  ])ain  and  tenderness  are  much  more 
localized,  and  there  is  spasmodic  fixation  of  the  trunk.  The  i^ain 
is  more  continuous  and  dull,  and  is  increased  by  lateral  pressure 
and  lessened  by  extension.  There  is  usually  also  some  deformity. 
If  compression  occurs  there  is  exaggeration  of  the  reflexes  and 
paraplegia,  without  much  anaesthesia.  After  all,  however,  with 
Pott's  disease  there  may  be  a  local  meningitis. 

Treatment.— X%  chronic  meningitis  is  usually  the  product  of 
syphilis  or  the  relic  of  traumatism  or  of  an  acute  process,  the  in- 
dications for  treatment  are  simple.  Rest  is  the  essential  thing. 
With  this  could  be  combined  the  systematic  and  persistent  use 
of  counter-irritants.  The  hot  iron  is  usually  best,  because  its 
wounds  heal  so  quickly.  Cupping  is  also  useful  if  done  vigor- 
ously and  often.  Internally,  iodide  of  potassium,  small  doses  of 
bichloride  of  mercury,  nitroglycerin,  and  digitalis  may  be  given ; 
also  the  salicylates  and  ergot.  Both  the  latter  drugs  should  be 
employed  in  large  doses,  if  at  all.  Electricity  in  the  form  of  gal- 
vanism and  cocaine  by  local  injection,  or  cata^jhoresis,  may  be 
tried. 

14 


CHAPTER  XIL 

MYELITIS-OFLAMMATION   OF  THE   SPINAL   CORD. 

Myelitis  is  an  inflammation  of  tlie  spinal  cord.  It  may  be 
acute,  subacute^  or  clironie. 

It  may  affect  the  anterior  horns  chiefly,  when  it  is  called  an- 
terior ^poliomyelitis  ;  or  both  the  gray  and  white  matter,  when  it 
is  called  diffuse  myelitis  and  transverse  myelitis.  The  forms  are 
still  further  divided,  in  accordance  with  their  location,  into  an- 
nular or  marginal  myelitis  where  the  inflammation  involves  the 
periphery  of  the  cord;  disseminated  myelitis  where  it  occurs 
isolated  in  different  parts  of  the  cord ;  x>eriependymal  myelitis 
where  it  surrounds  the  central  canal.  Myelitis  is  given  ditterent 
names  also  in  accordance  with  its  cause.  Thus  we  have  hemor- 
rhagic myelitis,  a  form  in  which  the  initial  process  is  due  to  or 
associated  with  a  hemorrhage;  compression  myelitis,  due  to  ver- 
tebral caries,  septic  or  purulent  myelitis  or  abscess  of  the  cord; 
and  tubercular  and  syphilitic  myelitis. 

For  practical  x^urposes  the  following  classification  is  sufficient: 

Acute  myelitis—  j    1,  Anterior  poliomyelitis. 

"With  exudation  and  necrosis.        (    2.  Transverse  myelitis. 

AVith  suppuration.  -    3.  Abscess  of  cord. 

^,         .  ,.^.  (4.  Chronic  anterior  polio- 

Chronic  myelitis—  y  r  if- 

With  necrosis  and  proliferation.  /    ^   ^      ^  .... 

^  ^   o.  Transverse  myelitis. 

f  6.  Marginal  myelitis. 

Rare  forms.  \  I  Periependymal  myelitis. 

j  8.  Disseminated  myelitis. 

L  9.  Compression  myelitis. 


Acute  Traxsverse  Myelitis  (Acute   Softexixg  of  the 
Spixal  Cord). 

Definition.— Acute  myelitis,  so  called,  is  generally  an  acute  soft- 
ening of  certain  parts  of  the  cord,  with  secondary  inflammatory 
reaction.  It  is  in  extremely  rare  cases  a  primary  exudative  and 
necrotic  inflammation.  In  other  rare  cases  the  inflammation  is 
suppurative,  and  we  then  have  spinal  ab.s-cess. 

Forms.— Tim  common  form  is  one  that  involves  one  or  two 


MYELITIS — INFLAMMATION  OF  THE  SPINAL  CORD.      211 

inches  vertically  of  the  spinal  cord,  and  is  hence  called  acttte 
transverse  myelitis.  Since  both  gray  and  white  matter  are  in- 
volved, it  is  also  called  a  diffuse  myelitis. 

Acute  transverse  myelitis  (softening)  is  the  commontype. 

An  acute  disseminated  myelitis  sometimes  is  met  with.  Other 
rarer  types  are  named,  in  accordance  with  their  location :  margi- 
nal, central,  or  periependymal.  There  is  also  an  acute  meningo- 
myelitis,  the  result  usually  of  a  meningitis. 

Etiology. — Predisposing  causes  are  a  neuropathic  constitution, 
the  male  sex,  early  adult  life,  occupations  calling  for  exposure, 
and  muscular  strain.  The  exciting  causes  are  exposure  to  cold, 
blows,  falls,  fractures,  strains,  extension  from  neighboring  organs, 
syphilis,  infective  fevers,  and  septic  infection.  Injury  is  the  most 
frequent  cause  and  syphilis  next.  But  most  of  these  causes  pro- 
duce primarily  mechanical  destruction,  hemorrhages  or  throm- 
boses, and  the  inflammation  is  secondary. 

Symptoms. — Prodromal  symptoms  are  rarely  present,  but  there 
may  be  slight  parsesthesise  or  pain  in  the  back  and  limbs.  Some- 
thiies  there  is  a  chill,  and  in  a  few  instances  convulsions  have 
been  noticed. 

The  initial  symptoms  consist  of  feelings  of  numbness,  usually 
in  the  feet  and  legs,  which  seem  heavy  and  weak.  Some  pain  may 
be  felt  about  the  back.  The  patient  soon  finds  that  he  cannot 
walk  easily  and  that  he  moves  his  legs  with  an  effort.  In  a  few 
hours  a  paraplegia  with  anaesthesia  has  developed,  and  if  the 
lesion  is  in  the  cervical  cord  the  arms  are  paralyzed  also.  All 
these  symptoms  may  come  on  in  the  day-time  or  during  sleep. 
Retention  or  incontinence  of  urine  and  constipation  are  early 
symptoms.     There  may  be  some  fever. 

Symjytoms  of  the  Attack. — If  the  patient  is  now  examined,  it 
will  be  found  that  he  cannot  walk  or  stand,  but  can  move  his 
legs  a  little.  He  complains  of  a  sensation  like  a  band  around  his 
waist  or  at  the  level  of  the  spinal  lesion  (girdle-symptom).  His 
legs  feel  numb  and  heavy,  but  there  is  little  pain  and  no  tender- 
ness. Anaesthesia  to  touch,  pain,  and  temperature  exist  in  vari- 
ous degrees  on  the  limbs  as  high  up  as  the  lesion.  The  anaesthe- 
sia, if  not  total,  is  greatest  to  touch,  next  to  temperature,  and  least 
to  pain.  He  has  vesical  anaesthesia,  the  urine  is  retained  and  he 
has  to  have  it  drawn.  The  bowels  are  constipated,  but  if  ene- 
mata  are  given  the  faeces  may  pass  away  without  his  knowledge, 
owing  to  rectal  anaesthesia.  If  the  lesion  is  lumbar  there  is 
abolition  of  the  sexual  power;  but  if  dorsal  or  cervical,  strong 
erections  may  occur  without  the  patient's  feeling  them.  When 
the  lesion  is  above  the  lumbar  cord,  also,  the  bladder  may  auto- 
matically and  forcibly  contract  and  expel  the  urine.  In  time  the 
bowels  regain  some  power.    The  paralysis  in  the  limbs  affects  the 


212  DISEASES   OF   THE   NERVOUS   SYSTEM. 

flexors  of  the  feet  and  legs  more  than  the  extensors.     The  patient 
can  push  down  his  hmbs  better  than  he  can  draw  them  up. 

Tiie  temperature  of  the  hmbs  for  a  few  days  is  raised,  but 
after  this  it  falls  a  few  degrees  below  normal.  The  skin  becomes 
rough,  cold,  congested;  and  excessive  perspiration  may  take 
place.  The  general  bodily  temperature  is  usually  normal  through- 
out the  disease,  but  in  some  cases  a  fever  develops  of  102'  to  101^ 
and  continues.     The  prognosis  is  then  bad. 

Bed-sores  may  develop  early,  within  a  few  days  or  weeks. 
They  appear  oftenest  upon  the  buttocks  and  heels,  and  are  due 
to  trophic  disturbance,  combined  with  pressure  and  pyogenic  in- 
fection of  the  parts. 

If  the  lesion  is  lumbar,  the  tendon  and  skin  reflexes  are  much 
weakened  and  the  paralysis  is  somewhat  flaccid.  The  muscles  also 
tend  to  waste  and  show  degenerative  reactions.  If  the  lesion  is 
dorsal,  as  is  more  often  the  case,  the  reflexes  are  present,  and 
after  a  time  become  exaggerated;  contractures  and  spasms  de- 
velop; the  legs  may  become  drawn  up  and  deformities  produced. 
If  the  lesion  is  so  complete  as  to  entirely  cut  across  the  cord,  there 
may  still  be  some  excessive  muscular  tension,  but  the  reflexes  will 
be  abolished  (Bastian).  When  the  cervical  region  is  attacked  the 
arms  are  involved  as  well  as  the  legs,  and  generally  to  a  severer 
extent.  There  may  now  be  also  unequal  dilatation  of  the  pupils 
from  involvement  of  the  cilio-spinal  centre;  and  optic  neuritis 
from  some  cause  has  been  known  to  occur.  In  extensive  involve- 
inent  of  the  upper  part  of  the  cord  there  may  be  paralysis  of  the 
intercostal  muscles  and  disturbance  of  the  heart's  action. 

The  disease  having  in  a  few  days  reached  its  height,  usually 
remains  stationary  for  a  few  weeks,  and  then,  should  the  patient 
live,  improvement  slowly  sets  in.  In  some  cases  evidences  of  ex- 
tension upward  or  downward  occur  (ascending  or  descending 
myelitis) ;  the  symptoms  become  more  severe,  and  in  a  few  weeks, 
or  oftener  months,  death  occurs. 

As  improvement  begins,  a  return  of  sensation  is  first  noticed 
(one  to  six  months);  this  is  followed  by  return  of  more  or  less 
motion  (six  to  eighteen  months).  Spasms  and  contractures  now 
develop,  owing  to  a  descending  degeneration.  A  certain  amount 
of  ataxia  from  ascending  degeneration,  with  a  little  anaesthesia  of 
the  skin,  may  remain,  so  that  if  the  patient  has  sufficient  motor 
power  to  walk  somewhat,  he  presents  many  features  of  "  ataxic 
paraplegia  "  (see  p.  249). 

Some  improvement  may  be  expected  for  from  one  to  two  years. 
A  few  cases  get  almost  entirely  well.  The  majority  become  more 
or  less  paraplegic  and  bed-ridden,  in  which  condition  they  are 
regarded  as  cases  of  chronic  myelitis. 

Fatholoijlral  Anatomy.— T\\q  early  changes  found   in  acute 


MYELITIS — INFLAMMATION  OF  THE  SPINAL  CORD.      213 

myelitis  are  those  of  inflammation,  hemorrhagic  extravasation, 
and  softening.  Often  it  is  impossible  to  say  whether  the  i^rimary 
process  was  inflammatory  or  due  to  a  hemorrhage  or  softening. 

Macroscopically^  the  cord  at  the  affected  part  appears  soft, 
swollen,  and  either  red  and  hyperiemic  or  i^ale  and  an^enjic.  In 
rare  cases  no  change  is  apparent  to  the  naked  eye.  In  later 
stages  the  parts  are  white  or  gray,  shrunken,  and  hard.  The  cord 
may  be  reduced  to  a  thin  shred.  The  meninges  about  the  affected 
I)arts  are  often  thickened,  inflamed,  and  adherent. 

Microscopically,  if  the  process  is  primarily  inflammatory  we 
find  intense  congestion,  distended  blood-vessels,  emigrated  Avhite- 
blood  cells  in  great  number,  especially  in  the  perivascular  spaces, 
swollen  axis  cylinders  and  oedematous  swelling  of  the  myelin 
sheath,  red-blood  cells,  cells  filled  with  fat  granules  known  as 
compound  granular  corpuscles,  or  Gluge's  corpuscles.  These  are 
leucocytes  which  have  taken  up  fat  granules.  A  jieculiar  form 
of  cell,  stellate  in  shape,  known  as  spider  cells  or  Deiter's  cells, 
may  be  seen.  They  are  proliferated  neuroglia  cells.  The  nerve 
cells  lose  their  granular  or  reticular  appearance,  become  homo- 
geneous, swell  up,  fat  granules  appear  in  them,  and  a  peculiar  co- 
agulation process  attacks  tlie  cell  and  body.  The  cell  processes 
retract,  become  thick, and  finally  drop  off.  Vacuoles  are  sometimes 
seen  in  the  nerve  cells ;  but  these  are  very  rare  if  the  tissue  is  prop- 
erly preserved.  Besides  the  above  evidences  of  vascular  and  con- 
nective-tissue activity  and  of  cell  destruction,  one  sees  granular 
matter,  broken-down  nerve  fibres,  and  other  evidences  of  nerve 
disintegration.  Pigment  or  extravasations  of  blood,  and  in  later 
stages  bodies  resembling  starch  granules  (corpora  amylacea),  may 
be  seen.  They  are  probably  modifications  of  the  myelin  substance. 
If  the  lesion  is  primarily  softening  there  may  be  much  congestion, 
but  the  blood-vessels  are  less  distended  and  fewer  Avhite  cells  are 
found  in  the  perivascular  spaces.  The  connective-tissue  cells  are 
less  numerous.  The  nerve  cells  are  swollen,  glassy,  and  stain 
badly.  There  is  a  great  deal  of  granular  matter  and  nerve  detri- 
tus. 

It  is  thought  that  in  inflammatory  swelling  of  the  nerve  cells 
they  take  up  the  carmine  stain,  but  in  degenerative  changes  they 
do  not.* 


*  lu  the  different  stages  of  acute  degeneration,  the  nerve  cells,  particularly  those 
of  the  anterior  horns,  show  various  appearances.  These  have  been  described  by 
Friedmann  as— 1,  homogeneous  swelling,  hyaline  swelling;  2,  sclerosis;  3,  simple 
atrophy;  4,  fatty  and  molecular  decomposition;  5.  cloudy  swelling.  The  degenera- 
tion begins  in  the  cell  body  and  then  involves  the  processes  and  the  nucleus;  finally 
the  whole  cell  is  involved.  Nerve  cells  do  not  often  undergo  the  acute  general  death 
called  coagulation  necrosis  (Friedmann),  though  the  process  of  sclerosis  so  called 
resembles  it  somewhat. 


214  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  connective-tissue  changes  are  most  noticeable  in  the  white 
matter.  The  axis  cylinder  and  myelin  sheath  are  here  often  so 
disintegrated  that  in  thin  sections  they  drop  out,  leaving  holes  in 
the  section  and  giving  it  a  vacuolated  appearance.  The  lesion, 
whether  destructive  or  inflammatory,  may  extend  up  or  down 
the  cord,  often  in  the  course  of  certain  tracts.  Sometimes  a  de- 
structive process  extends  a  long  way  through  the  central  part  of 
the  cord  (perforating  necrosis). 

After  three  or  four  weeks,  if  the  patient  lives,  the  process  of 
absorption  and  cicatrization  begins,  and  secondary  degenerations 
occur.  The  granular  and  fatty  matters  and  leucocytes  disap- 
pear, the  blood-vessels  are  thick-w^alled  and  distended  but  less 
numerous,  connective  tissue  gradually  takes  the  place  of  the  de- 
stroyed nerve  cells  and  fibres.  The  axis  cylinder  is  the  last  to 
be  destroyed  and  has  the  greatest  power  of  recuperation.  The 
nerve  cell,  if  once  destroyed,  is  never  developed  again.  The  cord 
at  the  point  or  points  inflamed  or  softened  becomes  reduced  to  a 
mass  of  connective  tissue  containing,  perhaps,  a  few  nerve  fibres 
and  cells.  In  this  stage  the  condition  is  one  that  is  known  as 
chronic  myelitis.  In  some  cases  a  cyst  is  formed  in  the  affected 
region. 

In  fatal  cases  the  inflammation  and  softening  continue ;  fresh 
areas  of  cord  are  involved,  much  meningeal  exudation  takes  place 
and  finally  death  occurs.  The  process  may  in  very  rare  cases  be 
still  more  acute,  suppuration  and  abscess  occur,  and  here  death 
also  rapidly  ensues. 

The  inflammatory  and  softening  processes  above  referred  to 
are  described  in  accordance  with  their  appearance  as  red  soften- 
ing, yellow  softening,  white  softening.  A  form  of  so-called  in- 
flammation known  as  inflammatory  oedema  is  also  described.  It 
js  an  abortive  inflammation,  "  a  lymphatic  congestion,"  analogous 
to  vascular  congestion. 

The  diagnosis  of  acute  myelitis  must  be  made  from  hemor- 
rhage, acute  embolic  or  thrombolic  softening,  acute  ascending 
paralysis,  multiple  neuritis,  meningitis,  and  meningeal  hemor- 
rhage, and  hysterical  or  functional  paralysis.  Spinal  hem- 
orrhage comes  on  suddenly  and  is  usually  not  attended  with 
fever.  If  meningeal,  it  is  attended  with  pain.  Acute  softening 
cannot  be  distinguished  from  acute  myelitis,  of  which  it  is 
probably  the  starting-point  in  many  cases.  In  acute  ascending 
Ijaralysis  the  disease  is  progressive, .  there  is  no  involvement  of 
sensation,  no  atrophy,  and  little  change  in  the  electric  irritability. 
In  multiple  neuritis  the  onset  is  slower,  there  is  more  pain  and 
local  tenderness  and  sensory  disturbance,  and  the  bladder  and 
rectum  are  rarely  involved.  In  meningitis  there  is  pain  and  ten- 
derness in  the  back  and  limbs,  rigidity,  cramps,  a  little  paralysis, 


MYELITIS — INFLAMMATION  OF  THE  SPINAL  CORD.      215 

and  no  bladder  trouble.  In  hysterical  paraplegia  there  are  no 
marked  atroj^hic  changes,  but  little  spasm  or  rigidity,  no  electri- 
cal changes,  and  the  stigmata  of  hysteria  may  be  found.  The 
sensory  disturbances  are  variable  and  somewhat  characteristic. 

The  diagnosis  of  the  location  of  the  lesion  is  made  by  studying 
the  height  of  the  amiesthesia,  the  skin  reflexes  (see  p.  190),  and  the 
distribution  and  extent  of  the  parah^sis.  Lesions  of  the  lumbar 
region  involving  the  gray  matter  cause  very  complete  paraple- 
gia with  sphincter  troubles  and  degenerative  electrical  reactions. 
Lesions  in  the  dorsal  cord  cause  a  less  complete  paraplegia,  but, 
owing  to  the  secondary  descending  degenerations  of  the  lateral 
column,  rigidity,  exaggeration  of  the  deep  reflexes,  and  contrac- 
tures occur.  Lesions  of  the  cervical  cord  cause  paralysis  of  the 
arms,  with  degenerative  reactions  in  the  muscles.  The  paraplegia 
is  spastic  and  there  is  not  much  muscular  wasting.  If  the  lesion 
cuts  ofT  the  cord  entirely,  the  limbs  are  paralyzed  and  may  be 
somewhat  rigid,  but  the  deep  reflexes  are  absent. 

Prognosis. — The  prognosis  is  worse  the  more  complete  and 
extensive  the  paralysis.  It  is  worse  in  serious  motor  paralyses 
than  when  sensation  is  chiefly  involved. 

It  is  best  in  dorsal  myelitis  and  worst  usually  in  cervical  mye- 
litis, other  things  being  equal.  Bed-sores  and  slight  fever  are  un- 
favorable signs,  so  also  is  severe  involvement  of  the  bladder  and 
rectum.  Recovery  of  sensation  gives  good  hope  of  recovery  of 
some  motion.  Total  absence  of  recovery  of  sensation  and  motion 
after  six  months  is  very  unfavorable.  Improvement  may  be  ex- 
pected up  to  eighteen  months  after  the  onset,  and  in  some  cases 
even  longer.  In  compression  myelitis  there  is  more  chance  of 
recovery  than  in  the  other  forms.  The  previous  existence  of 
syphilis  does  not  affect  the  prognosis  of  cases  of  true  myelitis. 

Treatment. — In  the  attack,  the  patient  must  be  put  to  bed, 
leeches  or  wet  cups  should  be  applied  to  the  spine,  diaphoresis 
should  be  promoted,  small  doses  of  aconite  and  nitroglycerin 
should  be  given,  and  a  calomel  purge  administered.  The  bladder 
s'hould  be  watched.  After  a  week,  moderate  doses  of  iodide  of 
potassium  should  be  given.  After  about  three  weeks,  if  there  is 
no  fever,  electricity  may  be  applied  carefully  and  strychnia  ad- 
ministered. Bed-sores  should  be  guarded  against  by  the  use  of 
water  beds  or  cushions,  absorbent  cotton,  bathing  the  parts  with 
alcohol  and  weak  solutions  of  tannin.  Infusion  of  buchu,  boracic 
acid,  and  tincture  of  hyoscyamus  will  often  help  the  bladder  dis- 
turbance. After  acute  symptoms  subside,  tonics  such  as  arsenic, 
iron,  and  strychnia  in  small  doses  may  be  given.  Suspension 
maybe  tried  carefully;  mechanical  appliances  may  be  used  to 
help  the  rigid  limbs;  lukewarm  baths,  douches,  and  massage  are 
helpful  to  some  extent. 


21C  DISEASES   OF   THE   NERVOUS   SYSTEM. 


Chronic  Myelitis   (ixcludixg  Transverse,  Diffuse, 
Disseminated,  and  Compression  Myelitis). 

Chronic  myelitis  is  the  name  given  to  a  disease  characterized 
by  a  elironic  inflammation  of  the  spinal  cord  and  to  the  chronic 
reparative  i^rooesses  which  follow  acute  inflammation,  injury,  and 
softening.  Chronic  myelitis  is  usually  a  mixture  of  inflammatory, 
reparative,  and  necrotic  processes. 

i^^07-/?2.y.— Different  names  are  given  to  chronic  myelitis  in  ac- 
cordance with  the  part  of  the  cord  affected.  Usually  the  disease 
affects  only  certain  levels,  and  then  it  is  called  transverse  mye- 
litis. More  rarely  it  is  diffuse  or  disseminated,  central  or  mar- 
ginal. When  caused  by  pressure  from  vertebral  disease  it  is 
called  comjyression  myelitis. 

Mioloyy.— The  disease  maybe  either  primary  or  secondary. 
The  2^rimary  form  is  much  the  rarer.  It  occurs  chiefly  in  adults 
and  in  early  and  middle  life,  and  much  oftener  in  males.  Expo- 
sure, shocks,  infectious  fevers,  lead,  and  syphilis  are  the  chief 
causes.  Syphilis  causes  it  by  producing  arterial  disease  and  by 
setting  up  a  specific  inflammatory  infiltration.  Secondary  chronic 
myelitis  is  the  more  common  form.  It  is  really  only  the  later 
stage  of  acute  myelitis,  softening,  hemorrhage,  or  injury. 

Meningitis  may  extend  and  cause  a  meningo-myelitis.  A  neu- 
ritis may  possibly  ascend  and  cause  myelitis,  but  such  cases,  if 
they  occur,  are  very  rare.  Compression  myelitis  is  usually  a 
slowly  destructive,  not  an  inflammatory  process,  and  it  begins  as 
a  meningitis  of  the  dura  mater. 

Symjytoins. — When  the  disease  begins  primarily  as  a  chronic 
affection  the  symptoms  are  as  follows: 

The  patient  notices  that  his  legs  are  heavy  and  get  easily 
tired ;  prickling  and  numb  sensations  are  felt  in  the  feet ;  occa- 
sionally a  little  pain  develops  in  the  back  or  there  is  a  sense  of 
constriction  about  the  trunk.  The  legs  feel  stiff,  and  tests  often 
show  that  the  reflexes  are  exaggerated.  There  is  but  little  wast- 
ing of  them,  however.  The  sexual  power  declines ;  the  bladder 
gives  some  trouble,  there  being  a  tendency  to  retention;  the 
bowels  are  constipated.  xVfter  a  few  weeks  or  months  there  is  a 
partial  paraplegia,  with  rigidity  of  the  limbs  and  exaggerated  re- 
flexes. Some  anaesthesia  exists,  and  occasional  pain,  which  is  not 
severe  and  is  felt  more  in  the  back  than  the  legs. 

The  muscles  have  now  wasted  soniewhat,  but  show  no  decided 
changes  to  the  electrical  current.  The  bladder  becomes  more  in- 
volved, the  urine  has  to  be  drawn,  it  is  often  alkaline,  and  unless 
care  is  taken  cystitis  develops.  The  patient  is  still  able  to  walk, 
but  he  does  so  with  a  stiff,  shuffling  gait  which  is  characteristic 


J 


MYELITIS— INFLAMMATION  OF  THE  SPINAL  CORD.      217 


(Fig.  93).  The  disease  may  show  signs  of  slowly  extending  up 
and  down,  more  often  up.  The  arms  become  involved;  weak- 
ness and  stiffness,  with  some  wasting,  anaesthesia,  and  pain,  de- 
velop, or  the  disease  may  cease  its  progress  and  the  patient  re- 
main partly  paralyzed  for  years.  The  general  health  during  the 
course  of  the  disease  deteriorates  slowly ;  the  patients  often  be- 
come anaemic  and  have  an  unhealthy  pallor.  Eventually  the 
paraplegia  becomes  complete,  the  patient  is  bed-ridden,  the  legs 
are  atrophied,  contractured,  and 
rigid,  with  more  or  less  anaesthesia. 
Cystitis  and  nephritis  develop,  or  the 
patient  dies  from  this  or  from  inter- 
current disease. 

Chronic  secondary  myelitis,  which 
is  the  form  commonly  seen,  presents 
eventually  much  the  same  picture  as 
that  just  described.  In  this  type, 
however,  the  symptoms  are  worse  at 
first,  then  improve  or  regress,  then 
become  stationary,  and  finally  grow 
worse. 

Symptoms  of  the  Different  Forms. 
—The  usual  type  of  chronic  myelitis 
is  the  transverse  dorsal  or  dorso-lum- 
bar,  and  this  gives  symptoms  as 
above  described.  If  the  lumbar  re- 
gion is  affected  there  is  more  para- 
plegia, wasting,  and  involvement  of 
organic  centres.  If  the  myelitis  is 
cervical  the  arms  are  involved,  there 
may  be  pupillary  changes,  and  the 
respiratory  muscles  are  partly  para- 
lyzed ;  the  paraplegia  is  not  so  com- 
plete and  the  disturbances  of  sensa- 
tion are  likely  to  be  more  varied. 

Comj^ression  myelitis,  so  called,  is  usually  only  a  compression 
atrophy.  It  is  due,  as  a  rule,  to  vertebral  caries,  but  its  cause 
may  be  a  spinal  tumor,  aneurism,  and  pachymeningitis.  Com- 
pression myelitis  is  distinguished  from  other  forms  by  its  slow 
onset  and  the  presence  at  first  of  irritative  or  "  root "  symptoms. 
The  patient  suffers  from  pain  and  tenderness  localized  at  a  cer- 
tain point  in  the  spine.  The  pain  radiates  about  the  trunk  or 
down  the  limbs  and  is  increased  on  movements.  At  about  the 
same  time  some  motor  weakness  develops,  usually  in  the  form 
of  paraplegia.  The  nmscles  waste  but  slightly.  The  reflexes 
are  exaggerated  ;  twitchings,  sjjasms,  and  contractures  finally  oc- 


-Attitude  in 

Myelitis. 


Chronic 


218  DISEASES   OF   THE   NERVOUS   SYSTEM. 

cur,  and  there  is  finally  developed  a  spastic  paraplegia  or  quadru- 
plegia.  Witli  this  there  is  usually  some  anesthesia,  though  it  is 
not  complete.  The  disease  is  oftenest  in  the  dorsal  or  lower  cer- 
vical region,  and  hence  the  sphincters  escape  until  late.  Locally, 
evidences  of  spine  disease  appear  early  in  the  form  of  a  kyphosis. 

A  central  ov  periependymal  myelitis  can  rarely  be  recognized 
with  certainty.  It  produces  less  pain  and  irritation,  but  leads  to 
muscular  atrophy,  disorders  of  sensations  such  as  thermo-anccs- 
thesia,  disturbance  of  vasomotor  and  secretory  nerves  and  vis- 
ceral centres. 

Pathology.— The  pia  mater  is  thickened  over  the  affected  re- 
gion and  often  throughout  the  cord.  The  cord  itself  has  a  gray, 
discolored  look  at  the  affected  level,  and  is  usually  shrunken  or 
distorted  and  hard  to  the  touch.  In  severe  cases  of  secondary 
character  it  is  reduced  to  a  small  size,  and  the  membranes  about  it 
are  thick  and  inflamed.  In  transverse  myelitis  a  vertical  area  of 
only  two  or  three  inches  is  involved.  The  microscope  shows 
that  the  prominent  changes  are  loss  of  nerve  structure,  great 
increase  of  connective  tissue,  and  increase  in  the  number  of  ves- 
sels which  often  have  thickened  walls.  In  the  more  seriously 
diseased  part  little  is  seen  but  connective  tissue.  In  parts  less 
diseased  some  nerve  fibres  are  seen,  many  having  evidences  of 
partial  disintegration.  There  is  also  a  good  deal  of  amorphous 
material  studded  with  nuclei.  Stellate  cells,  granule  cells,  and 
nerve  cells  in  various  stages  of  degeneration  are  present.  In  the 
parts  less  affected  the  signs  of  congestion  and  vascular  irritation 
are  more  pronounced. 

Diagnosis. — This  must  be  made  from  progressive  muscular 
atrophy  and  amyotrophic  lateral  sclerosis,  pachymeningitis  and 
spinal  tumor;  from  locomotor  ataxia  and  from  brain  palsies. 

In  progressive  muscular  atrophy  there  is  a  peculiar  atrophy 
without  involvement  of  the  sphincters  or  sensory  disturbance. 
In  pachymeningitis  there  is  often  a  history  of  an  injury;  there  is 
more  pain  in  the  back  and  a  more  marked  anaesthesia.  The 
sphincters  are  not  involved.  Pachymeningitis  is  also  usually 
located  in  the  cervical  region.  Tumors  usually  cause  much  more 
pain;  the  symptoms  come  on  slowly  and  are  more  definitely 
localized.  A  spastic  paraplegia  occurs  from  brain  disease  and  as 
a  functional  trouble.  In  either  case  there  are  no  trophic  or 
sensory  troubles,  nor  is  there  involvement  of  the  sphincters.  In 
locomotor  ataxia  there  is  no  great  degree  of  motor  paralysis,  and 
there  are  peculiar  ataxic  and  sensory  disturbances.  Paralysis 
from  brain  disease  is  almost  always  unilateral,  painless,  spastic, 
and  free  from  disturbance  of  the  visceral  centres. 

Prognosis. — Inflammatory  processes  have  a  tendency  to  cease 
when  their  reparatory  and  eliminative  work  is  done.     Chronic 


MYELITIS— INFLAMMATION  OF  THE  SPINAL  CORD.      219 

myelitis,  however,  is  often,  as  has  been  stated,  a  destructive  pro- 
cess due  to  some  defect  in  vascular  supply  or  to  some  mechanical 
irritation.  Besides  this,  in  the  spinal  cord  secondary  degenera- 
tions set  in  as  soon  as  certain  tracts  are  interfered  with.  Hence 
chronic  myelitis,  after  a  period  of  improvement,  generally  pro- 
gresses, and  the  prognosis  is  not  very  favorable.  Still,  patients 
may  live  from  five  to  twenty-five  years.  Dorsal  myelitis  is  the 
most  favorable  form;  compression  myelitis  from  caries  can  also 
often  be  successfully  treated.  Those  forms  which  come  on  rather 
rapidly  are  more  likely  to  cease  progressing  (Gowers).  Serious 
involvement  of  the  bladder  is  a  bad  sign,  and  naturally  the  prog- 
nosis is  worse  the  more  complete  the  paralysis. 

Treatment. — In  the  earlier  and  progressive  stage  of  chronic 
myelitis  rest  is  imperative.  The  patient  should  lie  down  much 
of  the  time.  Counter-irritation  in  the  form  of  fly  blisters,  the 
cautery,  or  setons  should  be  applied,  and  if  no  improvement 
results  wet  or  dry  cups  used.  The  descending  galvanic  current 
along  the  spine  should  be  tried;  faradism  and  massage  being 
used  upon  the  limbs.  Cold  baths  and  cold  applications  must  be 
prescribed  carefully  if  at  all.  Lukewarm  baths  90^  to  98  ^F.  or 
half-baths  with  friction  at  70°  to  80°  F.  are  more  likely  to  be  use- 
ful, but  even  these  must  be  tried  cautiously.  The  first  baths 
should  last  not  over  five  minutes  and  should  be  repeated  only 
three  or  four  times  weekly.  In  later  paraplegic  and  bed-ridden 
stages  electrical  and  hydro-therapeutic  applications  should  be 
followed  up  patiently  and  persistently.  The  patient  now  may 
be  allowed  to  remain  and  exercise  in  the  lukewarm  bath  for 
some  time. 

'Internally,  iodide  of  potassium  and  mercury  should  be  first 
given.  After  thorough  trial  with  these  remedies  for  six  or  eight 
weeks,  the  patient  should  be  given  courses  of  treatment  with 
arsenic,  nitrate  of  silver,  phosphorus,  and  perhaps  the  chloride 
of  gold.  Pills  of  arsenite  of  soda,  gr.  Jq,  may  be  administered  three 
or  four  times  daily  for  two  months;  if  benefit  ensues,  the  remedy 
should  be  resumed  after  an  intermission  of  three  weeks.  Phos- 
phorus is  best  given  in  the  form  of  Thompson's  solution  or  Sayres' 
elixir  in  doses  of  gr.  -^-^  ter  in  die  increased  to  gr.  ^^o-  The  remedy 
should  be  suspended  for  three  days  at  the  end  of  each  ten  days. 
Silver  is  given  usually  in  the  form  of  the  nitrate  (dose,  gr.  ^  to  i). 
Not  more  than  one  drachm  should  be  given  without  a  three- 
months  intermission.  Some  assert  that  the  hypophosphite  of 
silver  and  sodium,  or  the  albuminate,  are  surer  preparations.  I 
do  not  advise  the  use  of  ergot.  Strychnia  in  small  doses  some- 
times is  useful.  For  the  bladder  troubles,  the  internal  use  of 
boracic  acid,  buchu,  santalwood,  and  similar  drugs  are  useful. 
Mechanical  and  surgical  measures  may  be  of  some  help.     In  very 


^20  DISEASES   OF   THE   NERVOUS   SYSTEM. 

rare  cases  suspension  does  good,  but  it  may  do  harm.  Tenotomy 
is  justifiable  for  the  purpose  of  straightenino;  contracture  limbs. 
In  compression  myelitis  suspension  on  an  inclined  plane  and  the 
plaster  jacket  or  other  support  are  indicated.  Cases  have  been 
reported  in  which  surgical  operations  for  the  relief  of  a  supposed 
tumor  have  cured  compression  myelitis  from  Pott's  disease.  Sea 
voyages  are  often  useful  and  are  preferable  to  mountain  climates. 
Rest,  quiet,  fresh  air,  and  a  very  regular  life  are  the  essentials  in 
all  climates. 

Acute  Axterior  Poliomyelitis  (Ixfaxtile  Spixal  Paral- 
ysis, Acute  Atrophic  Paralysis). 

Anterior  poliomyelitis  is  a  disease  of  the  spinal  cord  charac- 
terized by  a  motor  paralysis  of  rapid  onset,  followed  by  muscular 
wasting,  without  sensory  symptoms.  It  occurs  at  all  ages,  but 
vastly  oftener  in  infancy ;  hence  it  is  often  called  infantile  spinal 
palsy. 

Etiology.— The  average  age  at  the  time  of  attack  is  two  years. 
Most  cases  occur  under  ten,  and  four-fifths  of  these  occur  under 
three.  It  may  be  congential,  i.e.,  occur  in  intra-uterine  life 
(Sinkler),  and  it  may  occur  as  late  as  sixty.  Most  adult  cases 
occur  under  the  age  of  thirty.* 

Rather  more  of  the  infantile  cases  occur  in  boys,  and  most  of 
the  adult  cases  occur  in  males. 

Race  and  climate  afford  no  exemption  so  far  as  is  known. 

The  great  majority  of  cases  occur  during  the  hot  months  of 
summer  (Sinkler),  Nearly  eightj^  per  cent  (78.8)  occur  between 
June  and  September,  inclusive. 

Heredity  has  an  influence  in  only  one  or  two  per  cent  of  cases. 

Over-exercise  and  chilling  of  the  body  Avhen  heated  are  occa- 
sional causes.  Infectious  fevers  (oftenest  measles)  precede  the 
attack  in  about  seven  per  cent  (Sinkler).  The  disease  has  been 
reported  to  have  occurred  as  an  epidemic  (Cordier).  Dentition  is 
rarely  an  exciting  cause,  as  used  to  be  supposed.  Injuries  and 
falls  in  a  few  instances  appear  to  be  the  cause  of  the  disease. 
The  fact  that  the  child  is  just  beginning  to  walk  at  the  period 
when  most  susceptible  to  poliomyelitis  must  be  considered  of 
importance,  since  the  new  movements  call  for  an  unusual  activity 
of  the  spinal  centres. 

*  Among  50  personal  cases,  39  were  in  children..  Of  the  latter  there  were  24 males, 
15  females.  Ages:  Under  six  months.  !;  half  to  one  year.  8;  one  to  two  j'ears,  10; 
two  to  three  years,  5;  three  to  four  years.  3:  four  to  six  years,  3;  six  to  eight  years, 
3.  Final  result  was  palsy,  chiefly  in  right  leg,  in  14;  chiefly  in  left  leg.  in  5;  in  both 
legs,  5;  in  right  ami,  4;  all  four  extremities,  1;  the  remainder  in  various  combina- 
tions. Disease  followed  scarlatina  in  1,  pertussis  in  2,  cholera  infantum  in  1,  some 
*'  fever  "  in  nearly  all  cases. 


MYELITIS— INFLAMMATION  OF  THE  SPINAL  CORD.      221 

To  sum  up,  age,  season,  and  infectious  diseases  are  the  three 
most  important  etiological  factors. 

iSy7npto?ns.— There  are  rarely  any  premonitory  symptoms.  The 
patient  is  taken  with  a  slight  fever,  100'  to  102%  accompanied  with 
vomiting,  diarrhoea,  or  convulsions.  In  a  few  hours  or  a  day 
paralysis  develops ;  sometimes  the  paralysis  is  as  much  as  a  week 
in  developing  ("  subacute  form ").  The  fever  lasts  from  one  to 
three  or  four  days.  The  paralysis  reaches  rapidly  its  height, 
then  remains  stationary  for  a  time;  then  improvement  sets  in, 
vhich  reaches  a  certain  point  and  then  stops. 

We  have  consequently : 

1.  A  stage  of  invasion — a  few  hours  or  a  week. 

2.  A  stationary  period — one  to  six  w^eeks,  usually  two  wrecks. 

3.  A  stage  of  improvement — six  months  to  a  year. 

4.  A  chronic  stage. 

1.  The  stage  of  invasion  may  be  so  sudden  as  to  suggest  hem- 
orrhage. Sometimes  the  child,  after  a  restless,  feverish  night, 
wakes  in  the  morning  paralyzed.  Usually  the  initiatory  symp- 
toms last  less  than  a  day.  With  or  before  the  paralysis  there  is 
a  fever  of  100^^  to  102°  P.,  vomiting,  delirium,  and,  much  less  often, 
convulsions,  which  are  not  severe.  After  the  general  disturbance 
subsides  there  may  be  some  pain  in  the  back  and  limbs  for  a  few 
days,  and  in  rare  cases  the  bladder  is  involved  so  that  there  is 
retention  of  urine.  But  the  dominant  symptom  is  motor  paral- 
ysis. 

The  paralysis  is  oftenest  paraplegia,  next  one  leg,  next  the 
arms  and  legs,  and  after  this  various  combinations.  The  eye 
muscles,  laryngeal  and  respiratory  muscles,  always  escape  in  in- 
fants. In  older  persons  the  facial  nerve  may  be  involved.  In 
certain  peculiar  cases  the  cranial  nerve  nuclei  are  attacked,  in 
association  with  the  anterior  horns.  When  the  eye  muscle  nuclei 
are  involved  it  is  called  "  polio-encephalitis  suj^erior ; ""  when 
cranial  nerve  nuclei  lower  down  are  involved  it  is  called  "  polio- 
encephalitis inferior." 

2.  The  i^aralysis  reaches  its  height  in  from  one  to  four  days. 
It  remains  at  its  height  for  from  one  to  six  weeks,  and  then 

improvement  gradually  sets  in.  In  two  or  three  weeks  a  wast- 
ing of  the  paralyzed  limb  may  be  noticed.  It  is  flabby,  its  tem- 
perature lowered,  and  the  reflexes  are  gone.  Slight  tenderness 
may  be  present,  but  there  is  no  anaesthesia. 

3.  The  stage  of  regression  lasts  for  from  one  to  six  months. 
There  is  gradual  improvement  of  the  paralysis,  beginning  in  the 
limbs  least  affected.  This  continues  until  the  paralysis  has  left 
all  but  one  or  two  limbs.  As  a  rule,  it  is  the  legs  alone  that  are 
finally  left  paralyzed.  In  a  quarter  of  the  cases  both  legs,  and  in 
half  of  the  cases  one  leg,  of tener  the  right,  remain  affected.     The, 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


inuscles  waste  and  show  reaction  of  deg:eneration,  viz.,  loss  of 
faradie  irritability,  retention  but  lessening  of  <?alvanic  irritability, 
sliijr^'ish  contractions,  and  sometimes  polar  changes.  In  the  leg 
the  anterior  tibial  group  of  muscles  is  oftenest  affected,  in  the 
arm  the  deltoid  and  shoulder  group.  The  atrophy,  having  reached 
a  certain  grade,  finally  ceases,  and  then  a  slight  improvement 
may  set  in.  After  the  end  of  a  year  not  much  further  spontane- 
ous improvement  can  be  expected. 

4.  The  temperature  of  the  affected  limb  is  lowered  several  de- 
grees, the  skin  has  a  reddish-purplish,  mottled  look.  The  bones 
as  well  as  muscles  of  the  affected  limbs  do  not  grow  as  fast  as 
those  of  the  healthy  limb.  Hence  in  time  the  foot  becomes 
smaller  and  the  leg  shorter.     Owing  to  the  contraction  of  unop- 


Flii.  'J4. 


FiG.  95. 


Fio.  94.— Anterior    Poliomyelitis    in    Lumbar    Segment,   showing    intense 
(Demaschino). 

Fig.  95.— Same,  Mcch  Enlarged,  showing  congestion. 

posed  nuLscles  deformities  occur.  The  most  frequent  are  talipes 
equinus,  talipes  vulgus  and  varus.  Deformities  of  the  knees, 
contrfiction  of  the  plantar  fascia,  lateral  curvature  of  the  spine, 
also  take  place.  The  general  health  of  the  patient  is  usually  good. 
PaUtolo(jy.—T\\Q  disease  is  an  acute  exudative  inlhuumation 
with  destruction  of  tissue,  but  without  suppuration.  It  affects 
chiefly  the  anterior  cornua,  especially  of  the  lumbar  and  cervical 
enlargements  (Figs.  1)4,  S)~)).  It  is  not,  as  a  rule,  diffuse,  but  often 
the  brunt  of  the  trouble  is  felt  only  by  certain  cell  groups.  These 
are  destroyed,  and  after  a  time  connective  tissue  takes  their  place. 
In  rare  cases  the  larger  part  of  the  central  gray  and  some  of  the 
white  matter  are  invf)lved.  Later  a  certain  amount  of  sclerosis 
occurs  in  the  lateral  columns.  The  anterior  roots  and  motor 
nerves  atrophy.  The  muscle  tissue  also  wastes,  and  its  place  is 
supi)lied  by  connective  tissue. 


MYELITIS— INFLAMMATION  OF  THE  SPINAL  CORD.      223 

Diagnosis. — The  disease  must  be  distinguished  from  multiple 
neuritis,  spinal  hemorrhage,  cerebral  palsies,  birth  j^alsies,  and 
progressive  muscular  atrophy.  The  diagnosis  can  be  easily  made 
in  almost  all  cases  by  remembering  these  facts : 

1.  The  age  of  the  patient. 

2.  The  abrupt  onset  and  rapid  development  of  extreme  paral- 
ysis. 

3.  The  tendency  to  improve, 

4.  The  absence  of  anaesthesia,  bladder  or  rectal  symptoms, 
rigidity,  and  j^ain. 

5.  The  electrical  reactions.  ---  ' 

6.  The  arrest  of  growth  of  the  limb.  Multiple  neuritis  and 
progressive  muscular  atrophy  rarely  occur  in  children.  Myelitis 
and  hemorrhage  are  usually  accompanied  by  sensory  disorders, 
bed-sores,  and  bladder  troubles ;  cerebral  palsies  are  usually  uni- 
lateral and  accompanied  with  symptoms  of  stiffness  and  exagger- 
ation of  reflexes. 

Prognosis. — The  patient  rarely  dies,  either  from  the  disease 
or  its  sequelae.  He  always  improves,  but  he  hardly  ever  gets  en- 
tirely Avell.  The  cases  in  which  recovery  is  complete  are  those  of 
simple  exudative  inflammation,  without  any  necrosis  (see  Acute 
Curable  Atrophic  Paralysis).  Much  can  be  done  by  careful  and 
persistent  treatment  and  by  the  help  of  orthopoedic  surgery,  even 
in  old  cases. 

The  usual  course  is  for  the  patient  to  get  back  the  use  of  all 
but  one  leg.  He  grows  to  adult  life  with  this  short  and  weakened 
member. 

Treatment.— In  the  acute  stage  the  child  should  be  put  to  bed 
and  kept  there.  Iodine  or  mustard  plasters  or  leeches  must  be 
applied  to  the  spine.  Internally,  a  smart  laxative  and  a  diuretic 
must  be  given  (calomel,  gr.  iij. ;  tartrat.  potas.,  gr.  xx.).  Then 
tincture  of  aconite  is  to  be  administered  in  doses  of  one  drop 
every  half-hour  as  indicated  by  the  fever.  To  this  may  be  added 
sweet  spirits  of  nitre.  Rest  is  the  most  essential  thing.  The 
limbs  should  be  kept  quiet  and  warm.  At  the  end  of  two  weeks 
electrical  applications  may  be  very  cautiously  made  to  the  limbs 
three  times  a  week,  if  there  is  no  tenderness  or  fever.  After  four 
weeks  electrical  treatment  should  be  given  daily  for  a  month, 
each  limb  being  treated  for  only  two  or  three  minutes.  After  a 
rest  of  a  fortnight  another  four-weeks  treatment  may  be  given. 
Treatment  should  be  thus  applied  intermittently  till  the  end  of 
a  year.  After  this  it  can  be  continued  or  stopped  according 
to  the  condition  of  the  patient.  In  old  cases  daily  treatment  for 
one  or  two  years  will  sometimes  produce  valuable  i-esults  (G.  M. 
Hammond).  That  form  of  electricity  which  causes  muscular 
contractions  most  easily  should  be  employed,  and  this  is  usually 


224  DISEASES   OF  THE   NERVOUS   SYSTEM. 

the  galvanic  current.  Massage  is  a  most  important  adjuvant  to 
electricity.  It  is  best  given  daily  for  not  over  ten  minutes  to  a 
single  limb.  It  is  imperative  also  that  the  physician  overcome 
any  contractures  which  develop  by  splints,  rubber  muscles,  and, 
if  necessary,  tenotomy.  Warmth  is  very  useful.  The  leg  should 
be  bandaged  in  cotton  at  night,  and,  if  necessary,  hot-water  bot- 
tles i^laced  beside  it.  Many  parents  cannot  afford  prolonged 
electrical  and  massage  treatment.  In  such  cases  they  should  be 
told  to  rub  the  limb  twice  daily  with  a  stimulating  liniment  and 
wrap  it  in  cotton  or  hot  flannels  at  night. 

The  child  should  be  taught  to  walk  and  exercise  the  limb 
as  much  as  possible.  Tricycles  and  gymnastic  apparatus  may 
often  be  brought  into  use  here. 

Medicines  are  of  little  value  in  the  chronic  stage.  Phosphorus, 
strychnia,  iron,  arsenic,  cod-liver  oil,  physostigma,  have  been  rec- 
ommended and  are  sometimes  prescribed  for  the  improvement 
of  the  general  health  and  solatii  causa. 

Chronic  Anterior  Poliomyelitis.— This  form  of  myelitis 
is  very  rare,  and  most  careful  examination  must  be  made  to  ex- 
clude on  the  one  hand  multiple  neuritis,  and  on  the  other  pro- 
gressive muscular  atrophy.  A  subacute  poliomyelitis  has  been 
described,  but  it  really  belongs  to  the  acute  forms. 

Mi ology.— Adults  are  chiefly  affected,  and  men  more  often 
than  women.  Exposure,  lead-poisoning,  and  syphilis  are  among 
the  principal  causes. 

*  8!jm2)toms. — The  disease  affects  one  or  more  of  the  extremi- 
ties, often  all  four  of  them.  There  is  a  gradual  paralysis,  rap- 
idly followed  by  atrophy,  with  degenerative  electrical  reactions. 
There  is  but  little  pain  or  other  sensory  disturbance.  The  sphinc- 
ters are  not  affected. 

The  disease  takes  one  of  two  courses : 

1.  After  reaching  its  height,  improvement  gradually  sets  in  and 
recovery  may  become  nearly  complete. 

2.  The  disease  steadily  progresses  until  the  patient  presents 
the  picture  of  a  case  of  progressive  muscular  atrophy.  In  a  few 
months  or  at  the  most  one  or  two  years  death  ensues.  Occasion- 
ally, however,  after  reaching  a  very  advanced  stage,  the  process 
stops  (Fig.  9G)  and  a  slight  improvement  may  set  in.  These  pro- 
gressive cases  of  chronic  poliomyelitis  appear  to  stand  half-way  be- 
tween ordinary  chronic  poliomyelitis  and  progressive  muscular 
atrophy  (see  Chronic  Atrophic  Paralysis  of  Erb). 

Diagnosis.— The  disease  is  distinguished  from  multiple  neuri- 
tis by  the  absence  of  pain,  tenderness,  and  ancEsthesia;  from  pro- 
gressive muscular  atrophy  by  the  rapid  onset,  the  occurrence  of 
paralysis  first  and  wasting  afterward,  the  early  degenerative  re- 


MYELITIS — INFLAMMATION  OF  THE  SPINAL  CORD.      225 

actions,  and  the  absence  of  fibrillary  contractions.     A  history  of 
lead-poisoning  may  also  help  in  the  diagnosis. 

The  treatment  is  mainly  symptomatic  and  must  be  carried  out 
on  the  lines  indicated  under  the  head  of  Acute  Anterior  Polio- 


FiG.  96.— Case  OP  Chronic  Anterior  Poliomyelitls  in  an  Adult,  showing  the 
wasted  hand  and  drop  foot. 

myelitis.    Iodide  of  potassium,  mercury,  and  strychnine  should  be 
given. 

MiA^OR  AND  Rare  Forms  of  Poliomyelitis. 

I.  Acute  Curable  Atrophic  Parctlysis  (Landouzy  and  Dejerine). 
— The  disease  comes  on  rapidly  with  little  constitutional  disturb- 
ance ;  it  afTects  profoundly  nearly  all  the  muscles  of  the  four  ex- 
15 


22G  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tvemities,  but  does  not  pick  out  groups.  The  cranial  nerves  are 
not  involved;  wasting  and  degenerative  reactions  are  present. 
There  is  no  sensory  disturbance  or  involvement  of  the  sphincters. 
It  is  a  simple  acute  exudative  inflaunuation,  probably  of  toxic 
origin,  and  should  be  classed  Avith  the  other  cases  of  anterior 
poliomyelitis. 

II.  Chronic  Atrophic  Paralysis  of  £">'&.— This  is  a  disef.se  hav- 
ino-  a  type  half  way  Ijetween  chronic  anterior  poliomyelitis  and 
progressive  muscular  atrophy.  The  name  had  best  be  given  to 
that  form  of  disease  which,  starting  like  poliomyelitis,  ends  as  a 
progressive  muscular  atrophy. 

III.  Subacute  Spinal  Paralysis  of  Pucheniie.— The  diseases 
described  under  this  head  are  chiefly  cases  of  multiple  neuritis. 
In  a  very  few  there  are  both  neuritis  and  myelitis ;  in  others  the 
condition  is  one  of  minute  focal  spinal  hemorrhages  with  second- 
ary myelitis.  There  is  probably  no  such  thing  as  a  "  subacute 
myelitis." 

Sexile  Paraplegia. 

This  is  a  form  of  paraplegia  occurring  in  persons  over  the  age 
of  fifty  or  sixty.  It  begins  A\ith  simple  weakness  of  the  legs,  fol- 
lowed by  wasting  and  progressive  development  of  a  pafraplegia. 
The  sphincters  become  eventually  involved.  The  disease  afTect? 
the  lower  extremities  first,  but  gradually  extends,  and  finally 
involves  the  arms.  The  general  characters  are  those  of  a  pro- 
gressive muscular  atrophy;  but  the  disease  is  distinguished  from 
this  by  the  fact  that  the  sphincters  become  rather  early  involved, 
and  that  the  paralysis  and  wasting  go  on  together  without  any 
fibrillary  contractions.  The  medulla  and  the  facial  and  ocular 
muscles  do  not  become  involved.  Clinicallj'  the  disease  cannot  be 
distinguished  from  a  chronic  anterior  poliomyelitis  which  takes 
upon  itself  a  progressive  type.  On  post  mortem,  however,  it  is 
found  that  there  is  a  softening  of  the  gray  matter  in  the  anterior 
horns  of  the  spinal  cord,  more  marked  in  the  lumbar  swelling. 
This  softening  is  apparently  due  to  the  thickening  and  oblit- 
eration of  the  blood  vessels  from  senile  changes  in  them.  Dr. 
Gowers  describes  a  disease  which  he  calls  senile  paraplegia  in 
Avhieh  there  is  simple  weakness  of  the  legs  and  slowness  of  move- 
ment, without  any  atrophy,  sensory  disturbance,  or  alteration  in 
the  reflexes.  He  considers  it  to  be  a  form  of  paralysis  agitans.  The 
disease  which  I  have  described,  however,  represents  more  truly  a 
simple  senile  paraplegia.  Very  little  can  be  done  for  this  trouble 
therapeutically.  The  use  of  nitro-glycerin,  iodide  of  potassium, 
sparteine,  digitalis,  and  general  tonic  and  hygienic  measures 
are  indicated. 


MYELITIS — INFLAMMATION  OF  THE  SPINAL  CORD.       227 


Acute  Ascending  Paralysis  (Landry's  Paralysis). 

Acute  ascending:  paralysis  is  a  disease  characterized  by  a  rap- 
idly developing  paralysis  which  begins  in  tlie  legs  and  then  in- 
volves in  turn  the  trunk,  arms,  respiratory  and  throat  muscles, 
usually  ending  in  death.  There  is  little  disturbance  of  sensation, 
no  atrophy  or  changes  in  electrical  irritability,  and  no  involve- 
ment of  the  sphincters. 

Etiology.— "The  disease  is  a  rare  one.  It  occurs  chiefly  between 
the  ages  of  twenty  and  forty;  men  are  affected  oftener  than 
women.  Exposure  is  an  exciting  cause,  and  it  occurs  sometimes 
after  acute  infectious  fevers  and  syphilis.  The  form  of  rabies 
known  as  "  paralytic  "  causes  a  disease  which  is  apparently  iden- 
tical with  Landry's  paralysis. 

Symptoms. — There  may  be  slight  premonitory  symptoms  for  a 
few  days,  consisting  of  numbness  in  the  extremities,  pain  in  the 
back  or  limbs,  and  malaise.  The  first  definite  sign  of  the  disease 
is  weakness  in  the  legs,  which  rapidly  increases  until  in  a  day  or 
two  the  patient  cannot  walk.  The  paralysis  soon  involves  the 
arms  and  then  the  muscles  of  respiration;  the  medulla  is  last 
affected,  and  then  respiration  becomes  difficult,  swallowing  and 
articulation  may  be  impossible.  In  rare  cases  there  are  facial 
and  eye  palsies.  During  the  course  of  the  paralysis  there  is  little 
pain  or  sensory  disturbance,  but  some  degree  of  ansesthesia  may 
occur.  The  deep  reflexes  are  abolished.  There  are  no  vasomotor 
and  no  secretory  disturbances,  no  noticeable  atrophy,  and  no  de- 
generative reactions  in  the  affected  muscles.  The  bladder  and 
rectum  are  involved  only  in  rare  cases.  There  may  be  slight 
initial  fever,  but  none  occurs  after  the  disease  has  well  set  in. 
The  mind  remains  clear. 

The  disease,  as  a  rule,  ends  fatally,  and  it  usually  runs  its 
course  in  less  than  a  week.  Death  has  occurred  in  forty-eight 
hours.  On  the  other  hand,  death  has  been  postponed  three  or 
four  Aveeks. 

Variations. — The  disease  has  been  known  to  begin  in  the 
medulla  or  cervical  region  and  descend. 

Pathological  Anatomy. — A  number  of  different  diseases  have 
been  described  under  the  head  of  Landry's  paralysis,  and  corre- 
spondingly a  number  of  different  anatomical  changes  have  been 
found.  Multiple  neuritis,  acute  diffuse  myelitis  and  poliomyelitis 
existed  in  some  cases.  In  others  there  was  a  dropsical  exudation 
in  the  central  canal  of  the  spinal  cord,  or  a  hyaline  change  in 
the  central  arteries.  In  most  instances  no  anatomical  change  is 
present. 

It  is  probable  that  in  true  Landry's  paralysis  there  is  no  lesion 


228  DISEASES   OF  THE   NERVOUS   SYSTEM. 

unless  the  disease  is  severe  and  prolonged.  The  paralysis  is  due 
to  a  poison  of  microbic  origin.  In  some  eases  certainly  this  poison 
is  that  of  rabies ;  but  it  is  not  impossible  that  other  infections 
may  pick  out  and  suspend  the  functions  of  the  anterior  cornual 
cells,  or,  as  Gowers  suggests,  the  "end-brushes"  of  the  motor 
tract  which  connect  with  these  cells.  This  would  ex^Dlain  the 
symptoms. 

Sometimes  the  poison  may  be  so  great  in  amount  and  so  irri- 
tating as  to  set  up  a  myelitis  or  perhaps  a  neuritis.  Cases  illus- 
trating these  facts  have  been  reported  (Eichberg,  Rosenheim, 
Putnam).  But  in  most  cases  the  imtient  dies  before  the  toxin 
can  produce  any  inflammatory  reaction. 

The  prognosis  is  very  grave,  but  not  absolutely  bad.  If  there 
is  reason  to  suspect  the  case  of  being  one  of  paralytic  rabies,  no 
hope  can  be  offered. 

Z)/«/7;/06/.y.— This  must  be  made  from  acute  poliomyelitis,  acute 
myelitis,  acute  multiple  neuritis. 

Its  acute  ascending  course,  absence  of  fever,  of  an£esthesia, 
atrophy,  decubitus,  sphincter  troubles,  and  especially  the  absence 
of  degenerative  electrical  reactions  are  sufficient  to  enable  one  to 
make  the  diagnosis. 

Treatment.— Th\^  consists'  of  warm  baths  or  packs,  counter- 
irritation  to  the  spine,  laxatives,  and  rest.  Large  doses  of  ergo- 
tin,  gr.  ij.,  every  hour  have  been  successful  in  one  case.  Salicylate 
or  benzoate  of  soda  may  be  tried. 


i 


CHAPTER   XIII. 


THE   DEGENERATIVE   DISEASES   OF   THE   SPINAL 

CORD. 

Introductory :  The  Nature  and  Types  of  Degeneration  and 
Sclerosis. 

The  degenerative  diseases  of  the  spinal  cord  are  sometimes 
called  "  system  diseases,"  and  some  are  often  spoken  of  as  scle- 
roses. There  are  no  true  system  diseases,  however,  except  loco- 
motor ataxia,  progressive  muscular  atrophy,  and  amyotrophic 
lateral  sclerosis.  These  diseases  attack  certain  columns  or  parts 
having  a  definite  jDhysiological  purpose.  Still,  even  they  are  not 
strictly  confined  to  these  parts,  and  the  term  "  system  diseases  " 
is  best  not  used  as  a  basis  of  classification.  The  term  "  sclerosis," 
also,  is  somewhat  misleading.  It  is  not  a  proper  word  to  indicate 
the  pathological  condition,  but  it  has  become  generally  adopted. 
Sclerosis  is  the  fibroid  (and  neuroglia)  induration  which  results 
from  degeneration,  destruction,  or  inflammation.  We  speak 
of  degenerative  sclerosis,  of  an  inflammatory  and  of  a  neuroglia 
sclerosis,  or  of  a  sclerosis  of  mixed  origin,  according  to  the  nature 
of  the  primary  disease.  The  words  "degeneration  "  and  ''  sclerosis  " 
are  often  used  to  indicate  the  same  thing,  one  being  the  patho- 
logical name,  the  other  the  anatomical.  I  shall  use  the  term 
"  sclerosis "  here  in  presenting  a  classification  of  the  degenera- 
tions and  scleroses  of  the  spinal  cord. 

f  I'  Posterior  spinal   sclerosis  (lo- 

I      comotor  ataxia). 

J  Combined  sclerosis. 

I  Multiple  sclerosis. 

I  Progressive    muscular     atro- 

(  Ascending  and  descending  de- 
l      generations. 

(  Chronic  myelitis   and   sclero- 
-!      sis  following  destruction  of 


Primarj^ 


Spinal  scleroses.  ^ 


Secondary. 

Inflammatory 
and  mixed. 


cord. 


I  have  already  described  the  scleroses  following  necrosis  and 
mflammation;    the   secondary  degenerations  and  scleroses  con- 


230  DISEASES   OF  THE   NERVOUS   SYSTEM. 

nected  with  these  processes  are  described  elsewhere.  Multiple 
sclerosis  is  a  cerebro-spiiial  disease  and  will  be  discussed  in  a 
later  chapter.  We  have  therefore  now  to  consider  the  prim- 
arj"  scleroses. 

TYie  primary  degenerative  scleroses  are  due  to  degenerations 
which  begin  in  the  nerve  tissue  and  end  in  its  atrophy,  with  sub- 
stitution of  connective  tissue.  As  to  their  nature  so  far  as  the 
microscope  shows  us,  it  is  a  gradual  decay  and  death  of  the  nerve 
fibre  and  cell.  In  some  fibroid  processes,  like  locomotor  ataxia, 
this  decay  is  accomiDanied  with  the  development  of  irritating 
products,  leucomaines  or  toxalbumins,  which  may  produce  so 
active  a  change  in  the  connective  tissue  as  to  lead  to  something 
resembling  a  secondary  or  reactive  inflammation.  This  is  never 
of  high  grade,  however,  and  in  some  forms  of  tabes  is  very  slight. 

In  progressive  muscular  atrophy  the  decay  and  death  produce 
few  irritating  iDroducts,  though  enough,  perhaps,  to  account  for 
the  fibrillary  twitchings  and  occasional  hypertonic  condition  of 
the  muscles. 

The  ultimate  cause  of  these  degenerative  processes  is  not 
known.  The  progressive  character  of  the  diseases  like  loco- 
motor ataxia  and  progressive  muscular  atrophy  would  lead  one 
to  think  that  there  is  a  poison  at  work  and  constantly  acting  on 
the  diseased  tissue. 

So  far,  all  bacteriological  examinations  have  failed  to  discover 
any  microbe,  but  the  fact  that  many  degenerative  processes  fol- 
low infectious  fevers  or  syphilis  has  led  to  the  suggestion  that 
pathogenic  germs  have  poured  into  the  system  a  poison,  or  have 
so  modified  the  cellular  nutrition  that  there  is  a  poison  constantly 
thrown  out  which  irritates  and  destroys  certain  areas  of  nerve 
tissue. 

All  the  primary  degenerations  or  scleroses  have  a  certain  de- 
gree of  kinship.  Their  causes  are  in  many  respects  the  same,  the 
course  of  all  is  uniformly  progressive,  and  one  not  very  infre- 
quently complicates  another.  The  sharpest  distinctions  are 
found  between  those  afTecting  the  gray  matter  and  those  affect- 
ing the  white.  Degenerative  processes  implicating  the  former  tis- 
sue are  nmch  rarer  and  their  course  is  more  rapid  and  fatal.  It  is 
the  anterior  and  central  parts  of  the  gray  matter  which  are  al- 
most exclusively  affected ;  consequently  we  have  clinically  only 
progressive  muscular  atrophy  and  its  allied  forms,  bulbar  pa- 
ralysis, ophthalmoplegia  externa,  and  amyotrophic  lateral  scle- 
rosis. 

The  degenerations  of  the  white  matter  are  more  common, 
slower  in  course,  different  in  etiology,  and  nnich  more  varied  in 
symptomatology.  As  a  rule,  the  gray  matter  is  not  much  in- 
volved except  secondarily  and  late. 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       231 


LOCOMOTOR  ATAXIA  (Posterior  Spixal  Sclerosis; 
Tabes  Dorsalis). 

Definition. — Locomotor  ataxia  is  a  chronic  progressive  disease 
of  tlie  spinal  cord  and  peripheral  nerves,  characterized  clinically 
by  inco-ordination,  pains, anesthesia, and  various  visceral, trophic, 
and  other  symptoms,  and  anatomically  by  a  degenerative  sclerosis 
chiefly  marked  in  the  posterior  columns  of  the  cord  and  posterior 
roots,  and  to  a  less  extent  in  the  peripheral  nerves. 

i^orm.9. -^Besides  the  common    and    typical  form,  there    are 

anomalous  and  complicated  types. 

r  1.  Common  form. 

m  2.  Neuralgic. 

Types.        ^   o    -n       1   f- 
[3.  Paralytic. 

i  4.  With  initial  optic  atrophy. 

(    With  mu^ular  atrophy. 
Complicated  )  ^y -^^^  ^^j^^^.  scleroses. 
forms.         /   ^vith  general  paralysis. 

Etiology. — The  disease  occurs  oftenest  in  middle  life,  between 
thirty  and  forty,  next  between  forty  and  fifty.  It  may  occur  as 
early  as  the  tenth  and  as  late  as  the  sixtieth  year.  In  the  very 
early  cases  it  is  usually  due  to  hereditary  syphilis.  It  is  much 
more  common  in  males.  Hereditary  influence  is  very  unimportant 
and  is  only  indirect,  i.e..,  the  parents  may  be  neurotic.  Diathetic 
influence  is  slight.  Exposures  to  wet  and  cold,  combined  with 
muscular  exertions,  are  effective  causes.  Soldiers,  travellers,  and 
drivers  are  rather  more  susceptible.  Excessive  railroad  travelling, 
excessive  dancing  with  exposure,  favor  the  development  of  the 
disease.  Excessive  sexual  intercourse,  combined  Avith  irregular 
living,  is  a  predisposing  cause.  Syphilis  is  a  very  important 
factor.  A  history  of  the  disease  is  obtained  in  from  one-half  to 
two-thirds  of  the  cases.  In  my  cases  about  forty  per  cent  had 
had  syphilis.  The  patient  usually  has  contracted  the  venereal 
disease  ten  to  fifteen  years  before,  and  has  rarely  had  noticeable 
secondary  symptoms.*  Syphilis  is  not  a  direct  factor,  but  pre- 
pares the  system  for  the  degenerative  process.  Syphilis  followed 
later  by  excesses — mental  or  physical— and  by  exposures  espe- 

*  Among  92  personal  cases  there  were  85  males,  7  females.  Ages  when  disease 
began:  Twenty-one  to  thirty.  15;  thirty-one  to  forty,  38;  forty-one  to  fifty,  29; 
fift}--one  tosixty,  8  ;  sixty-one  to  seventy.  2.  Syphilis  in  35;  doubtful  5 ;  denied,  43;  un- 
known, 9.  Americans  of  three  generations  or  more,  15  ;  English,  6  ;  Scotch.  2.  The 
rest  about  equally  divided  between  Irish  and  Irish-Americans,  German  and  German 
Americans.  Among  Americans  the  disease  apparently  begins  earlier,  and  paralytic 
forms  are  more  common.  The  duration  when  seen  had  averaged  five  or  six  years, 
ranging  from  one-half  year  to  twenty-  five  years.  The  time  between  infection  and 
the  beginning  of  the  disease  ranged  from  one  and  a  half  to  twenty-four  years,  aver- 
aging thirteen  years. 


232  DISEASES   OF  THE   NERVOUS   SYSTEM. 

cially  tends  to  produce  locomotor  ataxia.  Lack  of  proper  iodide 
treatment  also  favors  it. 

Among  other  causes  are  profoundly  depressing  emotions, 
acute  infective  diseases  like  typhus,  pneumonia,  and  rheumatism, 
difficult  labors  with  severe  hemorrhage,  prolonged  lactation,  in- 
juries with  shock,  and  excessive  smoking. 

Locomotor  ataxia  in  a  somewhat  atypical  form  may  result 
secondarily  from  gummatous  inflammation  of  the  spinal  men- 
inges, from  a  tumor,  and  possibly  from  an  ascending  neuritis. 

/Symj^toms.— The  disease  is  generally  divided  into  three  stages: 
the  initial  or  praeataxic,  the  ataxic,  and  the  paralytic. 

1.  The  initial  stage.  The  patient  first  notices  a  slight  uncer- 
tainty in  walking,  especially  at  night ;  he  has  numb  feelings  in 
his  feet,  and  at  times  darting  pains  in  the  legs  or  rectum.  His 
sexual  function  becomes  w^eak,  his  control  over  the  bladder 
slightly  impaired.  He  has  temporary  attacks  of  vertigo  and  of 
double  vision.  A  continuous  sense  of  profound  weariness  oppresses 
him,  even  though  he  has  made  no  exertion.  The  knee  jerk  is 
lost.     Such  symptoms  may  last  a  few  months  or  several  years. 

2.  The  ataxic  stage.  The  gait  now  becomes  so  unsteady  that 
others  notice  it ;  the  patient  has  to  use  a  cane,  and  when  walking 
watch  his  feet  and  the  ground.  If  he  stands  with  his  eyes  closed, 
he  totters  and  may  fall.  His  feet  feel  as  though  there  was  a  layer 
of  cloth  or  cotton  between  the  soles  and  the  ground.  Parox- 
ysms of  lightning-like  pains  attack  the  legs.  Tests  show  an- 
aesthesia present  in  the  toes  and  feet  or  in  xDatches  on  the  legs. 
A  sense  of  constriction  is  felt  around  the  waist.  The  sexual 
power  is  often  lost ;  the  bladder  is  weak,  and  care  has  to  be  taken 
to  empty  it.  The  bowels  are  constipated ;  at  times  he  has  attacks 
of  intense  pain  in  the  epigastrium,  with  vomiting  and  perhaps  a 
diarrhoea  coming  on  without  cause.  The  pupils  are  small  and  do 
not  react  to  light,  but  do  react  to  accommodation ;  vision  is  still 
good.  The  inco-ordination  and  pain  and  anaesthesia  after  a  time 
begin  to  affect  slightly  the  arms.     This  stage  lasts  several  years. 

3.  The  paralytic  stage.  After  several  years  with  various  re- 
missions and  improvements,  the  patient  loses  the  power  of  w\alk- 
ing  altogether.  His  legs  are  somewhat  wasted,  but  the  muscular 
strength  is  fairly  good.  The  anaesthesia  and  ataxia  are  very 
great.  The  patient  does  not  feel  the  prick  of  a  pin  or  touch  of 
the  hand ;  nor  with  closed  eyes  does  he  know  Avhere  his  legs  are. 
His  bladder  is  anaesthetic  and  paretic,  so  that  the  urine  has  to  be 
drawn.  The  pains  are  much  less,  but  are  still  present  at  times. 
The  arms  are  more  involved,  but  never  so  seriously  as  to  make 
them  useless  like  the  legs.  The  intelligence  remains  good,  and 
the  patient  may  continue  bed  ridden  for  years,  dying  finally  from 
some  intercurrent  affection. 


DEGENERATIVE    DISEASES   OF   THE   SPINAL   CORD.       233 


The  following  table  sliows  the  jjrominent  symptoms  in  the 
usual  order  of  their  aj^pearance : 


First  Stage. 
(Half  to  twenty  years.) 

Second  Stage. 
(Two  to  ten  years.) 

Third  Stage. 
(Two  to  ten  years.') 

Motor ^j 

Eye  palsies 

Less         

Increased 

Paresis 

Increased. 
Paraplegia. 

Muscular  weakness.. . . 

„                            \ 

Pains 

Pains 

Anaesthesia 

Pain  less. 
Increased. 

Sensory -J 

Excito-reflex  . .  -J 

Loss  of  knee  jerk 

A.  R.  pupil 

Trophic 

Arthropathies 

More  rare 

Rare 

Visceral    - 

1 

Sexual  weakness 

Vesical  weakness 

Constipation 

;-  Increased 

Increased. 

Special  senses. .  -| 

Diplopia 

Optic  atrophy 

■      7 

Increased. 

Tnf  rpasiprl 

I 

Paralysis  of  accom- 
modation. 

The  symptoms  must  now  be  analyzed  more  closely. 

Locomotor  and  static  ataxia  are  present  very  early,  but  only 
to  a  moderate  extent.  Tests  such  as  making  the  patient  walk 
and  stand  with  the  eyes  closed,  noting  the  position  of  limbs  and 
the  weight  of  objects,  will  reveal  an  ataxia  due  largely  to  begin- 


.— Instrument  for  Testing  Tendon  Reflexes. 


ning  anaesthesia  of  the  joints  and  tendons.  By  the  use  of  the 
ataxigraph,  one  can  with  care  assure  himself  that  the  patient  has 
an  excessive  degree  of  static  ataxia.  In  my  experience,  when  the 
ataxigraph  records  over  three  inches'  oscillation,  the  patient  not 
being  paraplegic  or  under  the  influence  of  any  drug,  it  is  abnor- 
mal. 

Tfie  patella-tendon  reflex  or  knee  jerk  is  abolished  very  early 
in  all  typical  cases.  This  constitutes  a  very  important  symp- 
tom, therefore. 

TJie  gait  and  station  in  ataxia  are  characteristic.  In  walking, 
the  patient  keeps  his  eyes  on  the  ground  and  on  his  feet.  The 
latter  he  throws  out  rather  forcibly,  owing  to  overaction  of  the 
extensors  of  the  foot.     In  watching  such  a  patient  walk  bare- 


234 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


footed,  the  extensor  tendons  can  be  seen  to  stand  out  with  each 
forward  movement  of  the  hmb.  The  foot  is  brought  down 
sharply  on  the  heel  and  the  legs  are  spread  apart  a  little. 
Turning  a  corner,  turning  around,  and  going  downstairs  are 
done  awkwardly,  and  the  patient  is  apt  to  totter  and  fall.  Walk- 
ing on  a  chalked  line  is  very  difficult;  so  also  is  walking  back- 
ward.    The  gait  improves  after  the  patient  walks  awhile,  and  he 

will  generally  say  that  the  prac- 
tice of  walking  does  him  good. 
Still,  he  soon  gets  tired  (Fig.  98). 

Severe  rectal  neuralgia,  as- 
sociated perhaps  with  haemor- 
rhoids, is  sometimes  an  early 
symptom.  Persistent  neuralgia 
and  functional  disturbance  of 
the  bladder  and  rectum  should 
cause  suspicion  of  ataxia.  Lan- 
cinating or  lightning  pains  occur 
and  are  very  characteristic.  The 
pains  dart  down  th^  legs  along 
the  course  of  the  sciatic,  or  they 
suddenly  appear  as  patches  of 
pain  on  the  foot  or  leg  or  thigh 
("  spot  pains  '').  The  pain  comes 
unexpectedly  and  with  such  se- 
verity that  the  patient  involun- 
tarily jumps  or  jerks  the  limb. 
He  speaks  of  his  "jerking"''  and 
"  twitching  pains.''  The  pains 
may  affect  the  bowels  or  be  felt 
as  a  squeezing  sensation  around 
the  waist  (girdle  pains).  The 
pains  of  ataxia  are  often  the 
most  obstinate  and  distressing 
symptom.  They  usually  come 
on  in  great  intensity  once  or  twice  a  month,  and  last  for  two 
or  three  days.  They  then  leave  the  patient  for  a  time.  They 
are  often  worse  in  cold  and  damp  weather.  In  some  cases 
the  pains  are  almost  continuous,  coming  on,  if  not  every  day, 
at  least  two  or  three  times  a  week.  Such  cases  are  associated 
with  much  cutaneous  hyperaesthesia,  especially  during  the  at- 
tacks. This  type  of  cases  is  called  "  the  neuralgic.''  The  pa- 
tients rarely  have  as  much  ataxia,  paresis,  or  visceral  troubles 
as  do  the  typical  forms,  and  in  certain  respects  such  cases  are 
favorable. 

The  pains  of  the  disease  continue  well  into  the  second  and  even 


Fig.  99.— Showing  Station  in  Second 
Stage  of  Locomotor  Ataxia. 


DEGENERATIVE   DISEASES   OF  THE   SPINAL   CORD.       235 

third  stage.  Meanwhile  tlie  anaesthesia  becomes  much  more 
marked.  It  affects  most  the  feet  and  next  the  legs,  rarely 
extending  much  over  the  thighs,  but  passing  to  the  fingers  and 
hands.  The  anaesthesia  is  greatest  to  pain,  but  touch  and  tem- 
perature sense  are  also  involved.  There  is  often  delayed  conduc- 
tion and  poly^sthesia;  many  other  curious  perversions  of  the 
cutaneous  sense  are  noted.     Some  anjesthesia  usually  develops 


Fig.  99.— Irregularly,  Contracted  Visual  Field  in  Case  of  Tabes  with  Optic 
Atrophy,  Left  Eye  (Berger). 


over  the  finger  tips  and  hands,  and  sometimes  a  band  of  anaes- 
thesia develops  about  the  waist.  The  facial  and  cranial  nerves 
are  not  much  affected,  but  there  may  be  trigeminal  neuralgia. 

Optic  atrophy  occurs  in  from  ten  to  thirty -five  per  cent  of 
cases,  according  to  statistics.  In  my  experience  the  percentage 
was  about  ten,  the  same  as  that  of  Gowers.  Optic  atrophy  usu- 
ally develops  in  the  prseataxic  stage.  If  a  patient  has  reached 
the  second  stage  without  it,  he  will  prohaUy  escape  it  altogether. 
Cases  with   ocular  paralyses  are  slightly  more  disposed  to  it 


230  DISEASES   OF   THE   NERVOUS   SYSTEM. 

(Berger).  It  attacks  the  left  eye  oftener  than  the  right.  The 
atrophy  begins  sometimes  with  increased  sensibility  to  light, 
flashes  of  light,  and  muscae  volitantes.  AVith  the  failing  vision, 
disturbance  of  color  sense  often  and  contraction  of  the  visual  field 
always  occur.  This  contraction  is  irregular,  with  sector-formed 
defects ;  not  hemiopic  (Fig.  99).  The  atrophy  progresses  slowly 
with  slight  remissions.  It  may  cease  its  progress,  but  this  is 
rare.  Blindness  comes  in  about  three  years.  Ophthalmoscoi^i- 
eally  there  may  be  seen  slight  evidence  of  congestion  in  the  early 
stage ;  later,  pallor  of  the  disc,  which  finally  becomes  grayish. 

Disorders  of  liearing  are  frequent  in  tabes,  occurring  in  about 
one-fourth  of  the  cases,  but  in  the  majority  of  instances  the 
aural  trouble  is  an  accidental  complication  due  to  middle-ear 
disease.  Primary  atrophy  of  the  auditory  nerve  is  very  rare,  as 
juight  be  expected,  since  this  nerve  is  structurally  not  like  the 
optic  nerve.  Its  existence  has  been  inferred  on  clinical  grounds. 
Another  form  of  tabetic  deafness  is  of  trophic  origin  and  due  to 
a  sclerotic  condition  of  the  middle  ear  (Treitel).  It  is  caused  by 
involvement  of  the  trophic  or  vasomotor  fibres  of  the  fifth  nerve. 

The  senses  of  taste  and  smell  are  rarely  affected. 

The  eye  muscles  are  implicated  in  some  way  in  nearly  all  cases 
of  tabes.     The  following  are  the  disorders : 

1.  Loss  of  the  light-reflex,  and  myosis.  2.  Sympathetic-nerve 
ptosis.  3.  Paralysis  of  branches  of  the  third  nerve.  4.  Paralysis 
of  the  sixth  nerve. 

Paralyses  of  the  ocular  niuscles  (third  and  sixth)  occur  rather 
oftener  in  syphilitic  cases.  Other  ocular  troubles  are  not  influ- 
enced by  a  preceding  syphilis.  Ocular  palsies  occur  relatively 
about  equally  often  at  the  various  ages  at  which  tabes  develops. 
They  are  early  symptoms  of  the  disease  occurring  as  a  rule  in  the 
praeataxic  stage. 

1.  Loss  of  light-reflex  and  pupillary  rigidity.  The  pupils  are 
small  and  sometimes  uneven ;  they  do  not  respond  to  light,  but 
they  do  to  accommodation.  This  condition  is  known  as  the 
Argyll-Robertson  pupil.  In  early  stages  the  light-reflex  may  be 
simply  sluggish.  In  the  late  stages  the  accommodation-reflex 
is  also  lost.  The  Argyll-Robertson  pupil  is  practically  onh^  found 
in  tabes  and  in  general  paresis.  The  ocular  skin-reflex  usually 
disappears  early.  The  myosis  in  tabes  is  due  to  paralysis  of  the 
sympathetic  dilating  fibres.  The  pupils  are  sometimes  irregular 
in  shape. 

2.  Sympathetic-nerve  ptosis.  A  slight  drooping  of  one  or  both 
lids  is  not  infrequent.  It  begins  early  and  progresses  slightly  up 
to  the  later  stages  of  the  disease.  It  is  due  to  paralysis  of  the 
sympathetic-nerve  fibres  of  the  lid. 

3.  4.  Paralysis  of  the  external  eye  muscles.     The  external  rec- 


DEGENERATIVE    DISEASES   OF   THE   SPINAL   CORD.       ^37 


tus  is  oftenest  aftected  of  single  muscles,  but  the  various  branches 
of  the  third  nerve  taken  together  are  oftener  involved  than  the 
sixth.  Of  the  third  nerve's  branches,  the  levator  palpebrse  and 
internal  recti  muscles  are  oftenest  involved.  There  may  be  mul- 
tiple palsies.  These  occur  oftener  in  syphilitic  cases.  Progressive 
ophthalmoplegia  may  be  associated  with  tabes.  The  ocular  nerve 
palsies  may  be  transitory  or  permanent.  Those  occurring  in  the 
prieataxic  stage  are  usually  transitory,  taking  a  few  hours,  days, 
or  weeks.  Cases  have  even  lasted  two  years  and  got  well.  The 
permanent  palsies  develop  usually  in  the  later  stages. 

The  arthropathies  of  locomotor  ataxia.  Degenerative  diseases 
of  the  joints,  technically  known  as  ar- 
thropathies, and  spontaneous  fractures 
of  bones  form  important  symptoms  of 
tabes.  They  occur  in  ten  per  cent  (Char- 
cot) or  five  per  cent  (author)  of  cases. 

The  arthropathies  are  three  or  four 
times  more  frequent  than  the  fractures. 
The  joints  oftenest  af- 
fected are  the  knees,  an- 
kles, and  hips;  but  the 
elbow,  shoulder,  wrist, 
and  small  joints  may  be 
attacked. 

Spontaneous  fractures 
occur  oftenest  in  the 
shaft  and  neck  of  the  fe- 
mur, next  in  the  legs, 
forearm,  humerus,  and 
clavicle.  The  j^elvis,  scap- 
ula, vertebrae,  and  undei- 
jaw  may  be  fractured. 
Arthropathies  are  often 
accompanied  with  frac- 
tures, especially  of  the 
heads  of  the  bones.  The  two  sides  of  the  body  are  about  equally 
affected. 

The  arthropathies  are  characterized  by  a  sudden,  apparently 
spontaneous  painless  swelling  of  the  joint.  The  symptoms  may 
develop  in  twenty-four  or  forty-eight  hours.  In  rare  cases  there 
is  a  history  of  some  preceding  rheumatic  pains  or  of  an  injury. 
After  a  time  there  is  an  osseous  hyperplasia  of  the  joint,  which 
becomes  enlarged  to  enormous  proportions  (Fig.  101).  There  is 
also  a  tendency  to  luxation  of  the  joint.  It  crepitates  on  mov- 
ing.     There  is  no  tenderness  on  pressure,  the  hand  finds 


Fig.  100.  --  Ar- 
thropathy OF 
Ankle. 


Fig.  101.— Arthropathy  op 
Knee  (A.  S.  Egberts). 


evi- 


dence of  synovial  exudation,  roughened   surfaces,  and  perhaps 


238 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


fractures  of  the  enlarged  parts.  In  the  milder  forms  there  is 
simply  swelling  from  synovial  exudation  and  some  enlargement 
of  the  bones  with  roughened  surfaces.  After  a  few  weeks  this 
sweUing  may  subside  and  the  joint  return  to  nearly  its  natural 
size.  In  other  cases  the  process  progresses,  the  ligaments  relax, 
the  bones  of  the  joint  can  be  moved  about  freely,  and  luxations 
are  easily  produced.     There  is  still  no  pain,  but  the  limb  becomes 


Fig.  102.— Arthropathy  involving  Knees  and  Long  Bones  of  Legs. 


almost  or  entirely  useless  on  account  of  the  loose  and  relaxed  con- 
dition of  the  parts  (Figs.  101,  103). 

As  time  goes  on,  some  absorption  takes  place  and  the  head  of 
the  bone  may  almost  disappear.  The  arthropathies  have  been 
divided  into  benign  and  malignant;  but  no  sharp  line  can  be 
drawn  or  certain  prognosis  made  in  the  early  stage. 

The  arthropathies  appear  in  the  i^rodromal  and  early  stage  of 
the  disease  in  over  half  the  cases,  and  are  often  at  first  unrecog- 
nized.    One-third  occur  after  the  tenth  vear  of  the  disease. 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       239 


The  spontaneous  fractures  are  usually  brought  on  by  a  slight 
trauma,  such  as  a  fall.  Violent  muscular  movements  may  pro- 
duce them.  They  also  are  painless  as  a  rule.  The  fractures  usu- 
ally heal  well,  often  with  abnormal  readiness,  but  occasionally 
there  is  delay,  and  often  healing  is  accompanied  with  great  throw- 
ing out  of  callus. 

Pathologically  the  arthropathy  is  a  rarefying  osteitis.  It  does 
not  differ  anatomically  from  arthritis  deformans,  except  that 
fractures  may  accompany  it.  Clinically  the  chief  difference  lies 
in  the  abruptness,  si^ontaneity,  and  painlessness  of  the  process. 
The  disease,  on  the  whole, 
cannot  be  considered  specifi- 
cally different  from  arthritis 
deformans,  modified  by  the 
analgesia  of  the  parts.  It  is 
due  probably  to  a  degenera- 
tive change  in  the  nerves 
supplying  the  joints  and 
bones.  The  process  may  be- 
gin in  the  cartilage,  bone,  or 
ligaments.  Eventually  all 
these  parts  are  involved. 
There  is  congestion  of  the 
synovial  membranes  with 
hydrarthrosis,  then  atrophy 
and  rarefying  hyi:)ertrophy 
of  the  epiphyses,  relaxation 
of  the  ligaments,  formation 
of  osteophytes  and  b  o  n  y- 
stalactites.  There  may  be  a 
rarefying  osteitis  of  the  long 
bones,  without  much  joint 
involvement  at  first  (Fig.  102), 

Various  trophic  distiirhances  of  the  skin  may  appear,  gener- 
ally late  in  the  disease.  The  most  common  are  herx)es  and  lichen. 
Besides  these,  bullae,  transitory  erythema,  urticaria,  eczema, 
pemphigus,  ecthyma,  ulcers,  ichthyosis,  and  petechice  have  been 
described ;  but  they  are  rare  and  often  only  accidenta  1  complica- 
tions. A  peculiar  round,  perforating  ulcer  sometimes  develops  on 
the  sole  of  the  foot,  often  as  the  result  of  cutting  a  corn.  In  rare 
cases  the  nails  and  teeth  fall  out.  In  syphilitic  cases  there  is 
usually  baldness. 

Peculiar  "  crises  "  of  various  kinds  occur  in  tabes.  The  most 
common  are  gastric  crises.  These  consist  of  attacks  of  in- 
tense pain  extending  from  the  groin  to  the  epigastrium  or  encir- 
cling the  waist,  accompanied  with  vomiting  and  sometimes  diar- 


FiG.  103.— Arthropathy  of  Elbow 

CA.  S.Roberts). 


240  DISEASES   OF   THE   NERVOUS   SYSTEM. 

rhoea.  The  attacks  are  usually  associated  with  pains  in  the  legs. 
They  last  two  or  three  days,  then  pass  away. 

Laryngtal  crises  consist  of  attacks  of  spasm  of  the  adductors 
or  paralysis  of  abductors,  with  noisy,  croupy  respiration.  The 
attacks  come  on  suddenly,  the  patient  coughs  and  struggles  for 
breath,  and  he  may  be  seized  with  vertigo  and  fall  down.  The 
pulse  may  be  very  fast.  The  paroxysm  lasts  for  a  few  minutes  to 
several  hours.  The  symptoms  are  very  distressing,  but  not  dan- 
gerous. Paroxysms  of  cough  have  been  described  as  "  bronchial 
crises."  There  are  also  cardiac  crises,  in  which  there  is  dysp- 
noea and  rapid  heart-beat  and  sense  of  suffocation  resembling 
angina.  The  heart  itself  sometimes  is  diseased,  but  whether  from 
neurotrophic  disturbance  or  not  is  doubtful.  The  pulse  is  often 
small,  rather  rapid,  and  weak. 

The  laryngeal  and  heart  crises  both  depend  on  a  degenerative 
irritation  of  the  vagus,  and  may  be  more  or  less  united  in  symp- 
toms. 

Ksense  of  great  weariness  and  heaviness  in  the  limbs,  present 
constantly,  no  matter  how  much  rest  is  taken,  is  a  characteristic 
symptom,  and  is  due  to  an  irritability  of  the  nerves  of  muscular 
sensibility. 

Iluscular  atrophies  occur  sometimes  in  tabes.  They  are  of 
three  kinds :  1st,  a  true  progressive  muscular  atrophy  due  to  de- 
generation of  troi^hic  and  motor  cells;  2d,  localized  muscular 
atrophies  due  to  degenerative  atrophy  of  nerves ;  3d,  a  general 
wasting. 

Under  the  first  head  one  finds  ophthalmoplegia,  bulbar  paral- 
ysis, and  spinal  amyotrophy.  Under  the  second,  wasting  of  cer- 
tain groui^s  of  muscles  in  the  legs  or  arms. 

Besides  these,  there  is  a  generalized  atrophy  which  occurs  in 
the  paralytic  stage  and  is  due  probably  to  a  slight  involvement  of 
the  anterior  horns  in  the  progressive  process  that  affects  the  cord. 

Attacks  of  hemiplegia  in  rare  instances  occur  in  tabes.  They 
are  usually  of  temporary  character  and  occur  early  in  the  disease. 
They  may  come  on  late  and  are  then  more  likely  due  to  acute 
softening. 

Acute  paraplegia  comes  on  occasionally  also,  and  this  some- 
times almost  disappears. 

The  sexual  poioer  maybe  at  first  greatly  exaggerated;  but 
this  is  rare,  and  usually  there  is  progressive  weakness  and  loss  of 
desire.  The  bladder  and  sexual  functions  are  rarely  entirely  lost 
and  rarely  equally  impaired  in  this  stage ;  one  may  continue  good 
while  the  other  is  affected  moderately.  Usually  the  sexual  func- 
tion goes  first. 

Some  cerebral  symptoms  occur  in  tabes,  chiefly  in  the  early 
stage.    They  are  insomnia,  which  may  be  very  obstinate,  and  occa- 


DEGENERATIVE   DISEASES   OF   THE   SPINAL.  CORD.       241 


sional  v^ertigo.    An  irritability  of  temper  and  tendency  to  despond- 
ency,  sometimes  _    ,.  - 
noted,     cannot    be 
considered  unnatu- 
ral.   Apoplectiform 
and  epileptiform  at- 
tacks are  described, 
but  are  very  rare, 
and  should  cause  a 
suspicion  of  a  com- 
plication.    The  disease  in 
very  rare  cases  terminates 
in  general  paresis. 

Course.  —  The  disease 
has  been  termed  progres- 
sive, but  it  is  not  so  in 
a  large  number  of  cases. 
With  proper  treatment  the 
symptoms  can  often  be  kept 
in  control  for  years.  The 
first  stage  may  last  twenty 
years  or  more;  the  second 
stage  five  to  fifteen  years. 
The  total  duration  of  the 
disease  varies  enormously, 
ranging  between  three  and 
thirty  years.  A  few  acute 
cases  have  been  observed, 
running  a  course  of  less 
than  a  year. 

Complications.  —  These 
are  acute  myelitis,  gener- 
ally syphilitic;  lateral 
sclerosis,  progressive  mus- 
cular atrophy,  hemiplegia 
from  embolism  or  endar- 
teritis, general  jjaresis,  and 
heart  disease. 

Pathological  Anatomy 
and  Pathology  .—The  GhsiY- 
acteristic  changes  are 
found  in  the  spinal  cord 
and  posterior  roots,  and  to 
a  less  extent  in  the  periph- 
eral   nerves.      The    spinal 

cord  usuallv  is  reduced  in  size  and  flattened  antero-posteriorly 
'i6 


Fig.  104.— Showing  Columns  of  Clark.  1, 
Normal ;  2,  diseased,  in  case  of  tabes  in  tliird 
stage;  with  degeneration  of  posterior  columns 
and  cerebellar  tracts  as  shown  in  3  (Oppenheim). 


242 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


the  pia  mater  is  thickened  somewhat.  One  can  see  with  the 
naked  eye  that  the  posterior  columns  of  the  cord  are  shrunken 
and  have  a  grayish  appearance. 

Under  the  microscope  it  can  be  seen  that  the  white  matter  of 
the  posterior  columns  is  very  seriously  affected ;  the  nerve  tissue 
has  disappeared,  and  its  place  is  taken  by  connective  tissue 
through  which  a  few  nerve  fibres  still  run.     The  walls  of  the 


h^.R 


Merve. 


Fig.  105.  Fig.  106. 

Fig.  105.— Posterior  Spinal  Gangi!.ion  in  Third  Stage  op  Tabes.   P.  R.,  Posterior 
A.  R.,  anterior  root  (Oppenheimj. 


root 

Fig.  106, 


-Healthy  Spinal  Ganglion, 


blood-vessels  are  somewhat  thickened,  but  not  remarkably  so,  nor 
is  there  any  notable  evidence  of  congestion  or  excessive  vascular 
irritation. 

The  part  of  the  posterior  column  first  affected  is  a  vertical  streak 
lying  in  the  middle  root  zone  beween  the  posterior  median  (col- 
umns of  Goll)  and  posterior  external  columns  (columns  of  Burdach) 
(Fig.  107).  The  segments  first  and  most  affected  are  those  of  the 
upper  lumbar  and  lower  dorsal  region.  Besides  this  area  the  rim 
zone  or  column  of  Lissauer  is  also  early  involved.     x\s  the  disease 


DEGENERATIVE   DISEASES    OF   THE   SPINAL   CORD.     243 


Fig.  107.  Fig.  108. 

Fig.  107.— Locomotor  Ataxia,  showing  areas  affected  in  first  stage  at  five 
different  levels.  Drawn  from  specimens  in  author's  possession  and  from  compara- 
tive study  of  over  thirty  other  figures. 

Fig.  108.— Locomotor  Ataxia,  Second  Stage. 


244 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


Fig. 


109.— Locomotor  Ataxia, 
Last  Stage. 


progresses  it  extends  uiDward 
and  spreads  laterally  so  that 
finally  all  of  the  posterior  col- 
umn is  changed  into  a  dense 
connective-tissue  mass  through 
which  only  a  few  nerve  fibres 
run.  The  part  last  and  least 
involved  is  that  lying  just  pos- 
terior to  the  commissure  (ante- 
rior root  zone  of  Flechsig)  and 
that  lying  just  mesial  of  the 
posterior  horns  (external  part 
of  the  middle  root  zone).  There 
is  sometimes  a  degeneration  of 
the  antero-lateral  ascending 
tract  (Gowers'  tract)  and  very 
rarely  of  the  cerebellar  tract. 
The  pyramidal  tracts  are  only 
involved  in  complicated  cases. 
The  cells  and  fibres  of  the  col- 
uilin  of  Clark  are  often  in- 
volved in  advanced  cases  (Fig. 
104).  The  gray  matter  of  both 
the  posterior  and  anterior 
horns  may  show  some  degener- 
ative changes,  viz.,  decrease  of 
the  fibre  network  and  atrophy 
of  the  cellular  elements. 

The  posterior  roots  are  usu- 
ally involved,  the  process  ex- 
tending as  far  as  the  spinal 
ganglia,  which  also  show  some 
degeneration  (Figs.  105,  106). 
The  anterior  roots  are  normal. 

The  process  begins  in  the 
upper  lumbar  cord  ;  the  sacral 
cord  is  usually  much  less  af- 
fected. However,  the  exact  in- 
itial point  of  attack  varies,  and 
this  accounts  for  the  variation 
in. the  symptoms.  Cases  that 
begin  with  decided  bladder  and 
genital  symptoms  probably 
start  low  down ;  cases  which  go 
for  a  good  while  with  only 
ataxia,  loss  of  knee  jerk,  and 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       245 

pains  begin  higher ;  while  in  the  brachial  or  arm-type  cases  the 
process  begins  in  the  cervical  enlargement. 

The  peripheral  nerves  are  diseased  in  a  large  number  of  the 


Fig.  110.— Plantar  Nerve  Simple  Atrophy  in  Tabes. 

advanced  cases.  The  nerves  of  the  leg  are  most  involved.  The 
process  is  a  degenerative  atrophy  or  neuritis  (Figs.  110,  111).  It 
affects  the  extremities  of  the  nerves  first  and  slowly  extends 
upward,  seldom  reaching  the  large  trunks. 


Fig.  111.— Ulnar  Nerve  Third  Stage  Tabes,  Atrophy  with  Proliferation  of 
Connective  Tissue  (Oppenheim). 

In  the  early  stage  the  only  nerve  that  is  often  affected  is  the 
optic.  The  process  here  is  an  atrophy  beginning  at  the  periphery 
and  extending  brain  ward.     The  third,  fifth,  and  sixth  nerves  are 


246  DISEASES  OF  THE  NERVOUS  SYSTEM. 

occasionally  involved ;  still  more  rarely  the  olfactory  and  aadi- 
torv.  The  vagus  nerve  and  sometimes  its  nucleus  and  that  of 
the'  glosso-pharyngeal  are  implicated,  it  may  be,  rather  early  in 
the  disease.  It  is  believed  that  these  facts  explain  many  of  the 
laryngeal  and  visceral  crises. 

The  disease  is  primarily  an  irritative  degeneration.  The 
nerve  fibres  of  the  cord  are  first  involved.  Their  destruction 
is  not  a  simple  wasting,  but  is  accompanied  with  evidence  of 
irritation  such  as  swelling  of  axis  cylinders  and,  secondarily, 
proliferation  of  connective  tissue  and  slight  congestion.  The 
disease  is  spoken  of  by  some  as  a  parenchymatous  inflammation 
(Charcot) ;  by  others  as  a  vascular  sclerosis ;  by  others  as  a  gliosis, 
i.e.,  a  substitution  of  neuroglia  tissue  for  nerve  fibre.  In  the 
light  of  present  knowledge,  however,  it  is  safest  to  saj^  that, 
through  some  toxic  or  diathetic  influence  constantly  acting,  there 
is  set  up  a  progressive  destructive  process  which  has  a  selective 
influence  on  certain  tracts  in  the  posterior  columns  with  their 
roots  and  ganglia  and  to  a  less  extent  on  the  peripheral  nerves, 
particularly  the  optic. 

The  diagnosis  is  not  difficult  in  the  advanced  stages.  In  the 
first  stage  the  disease  has  to  be  distinguished  from  multiple  neu- 
ritis, chronic  myelitis,  spinal  tumor,  spinal  syphilis,  general  pare- 
sis, and  neurasthenia.  Multiple  neuritis,  in  its  sensorj^  or  pseudo- 
tabetic  form,  sometimes  resembles  closely  locomotor  ataxia.  The 
differential  points  are  given  under  that  disease. 

In  myelitis  there  is  more  paralysis,  generallj^  exaggeration  of 
reflexes,  and  an  absence  of  disturbance  of  special  senses. 

The  diagnostic  criteria  of  locomotor  ataxia  in  all  cases  are 
the  presence  of  lightning  pains,  numbness  of  the  feet,  loss  of 
knee  jerk,  ataxia  of  station  and  gait,  without  much  loss  of 
muscular  j)ower,  the  presence  of  the  Argyll-Robertson  pupil,  the 
history  of  syphilis,  and  the  slow  onset  of  the  disease. 

Prognosis. — In  the  first  stage  a  small  percentage  may  have  the 
disease  stopped  and  get  practically  well.  After  the  second  stage 
a  cure  is  impossible,  but  great  improvement  may  be  secured  and 
the  x^atient  made  relatively  comfortable  for  years. 

In  the  third  stage  little  can  be  done  except  relieve  the  symp- 
toms, but  life  may  be  prolonged.  Death  usually  occurs  from 
some  intercurrent  malady,  or  from  kidney  disease  caused  by 
the  bladder  trouble.  Patients  very  rarely  indeed  die  from  the 
disease  itself  and  its  various  "crises."' 

Treatment.— T\ie  hygienic  treatment  consists  in  enforcing  a 
very  regular  and  quiet  life.  The  meals,  sleep,  work,  and  exercise 
should  be  taken  in  the  most  systematic  way.  It  is  often  best 
when  possible  to  have  the  patient  give  up  business.  This  is  es- 
pecially necessary  if  the  business  involves  great  mental  and  phy- 


DEGENERATIVE   DISEASES   OF   THE   SPINAL  CORD.       247 

sical  strain.  Absolute  rest  in  bed  for  several  months  is  often 
very  helpful,  especially  in  neuralgic  cases.  Out-door  country  life 
is  better  than  city  life.  Climates  of  low  altitude,  if  not  very 
moist,  are  better  than  high  altitudes.  Sea  voyages  are  often 
helpful. 

A  diet  which  is  non-fermentative  and  easily  digestible,  i.e.,  a 
nitrogenous  diet,  is  preferable.  The  absolute  diet  of  meat  with 
hot  Avater  seems  rarely  indicated,  and  has  not  proved  useful  in 
my  experience. 

Hydrotherapy  is  much  employed  in  Germany.  I  have  found 
lukewarm  baths  at  a  temperature  of  95°  F.,  for  ten  or  twenty 
minutes  daily,  helpful  in  some  cases,  especially  in  early  stages. 
Later,  cold  allusions  over  the  back  may  do  much  good. 

Electricity  is  of  use  from  its  general  tonic  and  reflex  effects, 
and  perhaps  exercises  some  direct  influence  on  the  diseased  pro- 
cess. Strong  galvanic  currents  (15  to  30  ma.)  should  be  applied 
along  the  spine,  through  the  trunk,  and  down  the  legs  and  arms. 
The  combined  galvanic  and  faradic  current  is  even  better,  given 
in  the  same  way.  The  faradic  brush  should  be  applied  over  the 
extremities  and  along  the  back. 

The  actual  cautery  is  efficient  in  stopping  pains.  It  should 
be  applied  to  the  back  as  often  as  once  a  month  at  least  and 
sometimes  once  a  week.  Dry  cups  may  be  applied  rapidly  and 
in  great  number  (80  to  100)  along  the  spine  and  along  the  course 
of  the  sciatic  nerves.  In  very  painful  cases  occasional  wet  cups 
and  leeches  are  useful.  Blisters  and  various  forms  of  counter- 
irritants  sometimes  do  good. 

Suspension  by  the  neck  and  arms  is  helpful,  beyond  any  doubt, 
in  about  fifteen  per  cent  of  the  cases.  It  is  best  adapted  to  per- 
sons in  the  second  stage  and  to  those  who  have  a  good  deal  of 
bladder  trouble  and  pain.  It  is  of  little  value  in  th.e  paralytic 
stage  and  must  be  used  with  care  in  the  early  stage.  Suspensions 
should  be  given  for  one  to  three  minutes  three  times  a  week  until 
twenty-five  or  thirty  are  taken.  After  three  months  a  second 
course  may  be  given.  The  various  ingenious  modifications  of 
suspension,  by  which  the  back  is  flexed,  extended,  or  stretched 
by  weights  and  pulleys,  have  not  been  shoAvn  to  have  any  ad- 
vantage. 

Medicinally,  for  the  diseased  condition  itself  it  is  customary 
to  give  iodide  of  potash,  arsenic,  strychnine,  phosphorus,  nitrate 
of  silver,  chloride  of  gold  and  sodium,  ergot,  mercury,  and  chlor- 
ide of  aluminium.  I  doubt  if  any  of  these  drugs  are  of  value  ex- 
cept silver,  and  sometimes  the  iodide,  bichloride  of  mercury,  and 
gold.  Of  them  silver  is  the  best,  and  appears  undoubtedly  to 
affect  favorably  the  course  of  the  disease.  Various  salts  of  silver 
are  used,  but  none  have  any  special  demonstrated  value  over  the 


248  DISEASES  OF  THE  NERVOUS  SYSTEM. 

nitrate,  which  should  be  given  in  doses  of  gr.  i  to  f  ter  in  die  for 
not  over  two  months  at  a  time.  Arsenic  is  recommended  by 
Gowers,  but  I  have  not  seen  it  do  any  good.  The  same  author- 
ity recommends  chloride  of  aluminium  in  doses  of  gr.  ij.  to  iv. 
Symptomatically  the  drugs  most  called  for  are  those  which  re- 
lieve pain.  Phenacetin  and  antipyrine  stand  at  the  head  of  the 
list,  but  antifebrin,  extract  of  Cannabis  indica,  codeine,  aconitine, 
exalgin,  salicylate  of  sodium,  muriate  of  ammonia,  all  may  have 
to  be  tried.  Relief  from  pain  is  gotten  by  using  lukewarm  baths 
with  pine-needle  oil  or  extract,  by  aj^plying  ice-bags,  and  by 
wrapping  the  limbs  in  flannel  bandages  into  which  sulphur  and 
menthol  have  been  rubbed.  Bladder  troubles  are  often  much 
relieved  by  infusion  of  buchu  3  ij.  and  tincture  of  hyoscyamus 
TTl  X.  every  three  hours,  or  by  sandalwood  oil.  In  vesical  and 
rectal  neuralgias,  suppositories  containing  iodoform  gr.  iij.,  ex- 
tract belladonna  gr.  ^,  and  codeine  or  antipyrine  may  be  used. 


Locomotor  Ataxia  in  Children. 

The  spinal  cord  of  persons  under  the  age  of  puberty  is  not 
subject  to  primary  systemic  -degenerative  changes.  This  is  a 
general  law  to  which,  aside  from  the  cases  of  Friedreich's  ataxia, 
there  are  hardly  an}^  exceptions. 

The  posterior  columns  alone  are  sometimes  primarily  affected ; 
but  in  almost  all  instances  the  disease  takes  the  type  known 
as  Friedreich's  ataxia,  and  it  may  be  seriously  doubted  whether 
tabes  dorsalis  ever  shows  itself  in  young  children  in  any  other 
way  than  as  hereditary  syphilis  or  as  the  peculiar  form  known 
as  degenerative  or  Friedreich's  ataxia. 

Still,  a  few  cases  have  been  reported  in  which  an  apparently 
typical  tabes  began  between  the  ages  of  nine  and  twenty. 


THE   COMBINED   SCLEROSES. 

By  the  combined  scleroses  is  meant  those  forms  of  degenera- 
tive sclerosis  in  which  both  the  posterior  and  lateral  columns  are 
involved.  There  are  several  diseases  in  which  combined  sclero- 
sis exists.     They  are : 

1.  Ataxic  paraplegia 

2.  Friedreich's  ataxia. 

8.  Complicating  scleroses  of  general  paresis. 

Besides,  there  are  numerous  irregular  forms.  One  of  these 
has  a  tolerably  definite  clinical  course  and  may  be  termed 

4.  Combined  sclerosis  with  terminal  softening.  It  has  been 
described  most  fully  by  J.  J.  Putnam. 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       249 


Ataxic  Paraplegia  (Progressive  Spastic  Ataxia). 

This  is  a  disease  characterized  by  the  symptoms  of  spastic 
paraplegia  and  ataxia. 

Etiologi/.— Ataxic  paraplegia  is  not  a  special  and  independent 
disease.  It  has  not  a  definite  pathological  basis.  It  is  a  clinical 
symptom -complex  to  which  a  special  name  is  given  for  the  sake 
of  convenience.  Nearly  all  cases  of  ataxic  paraplegia  are  cases  of 
chronic  myelitis  of  the  dorsal  region,  with  secondary  degenera- 
tions, or  cases  of  locomotor  ataxia  with  a  complicating  or  second- 
ary degeneration  in  the  lateral  column.  In  my  experience,  ataxic 
paraplegia  is  oftenest  an  atypical  form  of  locomotor  ataxia.  In 
some  cases  a  myelitic  focus  may  set  up  true  primary  degenera- 
tive changes  in  the  cord  in  parts  remote  from  the  focus.  Bear- 
ing the  above  facts  in  mind,  it  is  unnecessary  to  go  further  into 
the  etiology  of  the  disease,  it  being  caused  by  the  same  factors 
that  cause  chronic  myelitis  and  locomotor  ataxia.  It  is  a  dis- 
ease of  early  and  middle  life  and  of  men. 

The  symptoms  are  those  of  a  gradually  developing  spastic 
paraplegia  plus  more  or  less  ataxia.  The  first  symptoms  are  a 
heaviness,  numbness,  and  stiffness  in  the  lower  limbs.  Ataxia 
develops  early. 

It  is  shown  in  standing  and  walking  and  in  attempting  to 
make  co-ordinate  movements.  It  is  present  even  when  the  mus- 
•  cular  sense,  as  tested  by  posturing  the  limbs  and  by  weights,  is 
shown  to  be  good.  It  involves  the  arms  but  little.  The  gait  is 
a  combination  of  that  in  tabes  and  in  spastic  paraplegia.  The 
heels  are  brought  down  first  in  some  cases,  in  others  the  toe  drags 
and  the  heel  strikes  the  floor  last.  Sometimes  the  whole  foot  is 
planted  down  at  once,  and  the  shoes  are  worn  almost  evenly. 

The  deep  reflexes  are  exaggerated  and  there  is  trepidation  and 
clonus.  Muscular  weakness  is  not  very  great,  but  some  is  present 
and  eventually  becomes  marked.  There  is  little  or  no  atrophy. 
There  is  but  little  anesthesia  and  rarely  much  pain,  nor  are 
there  often  visceral  crises.  The  eyes  are  rarely  involved.  There 
is  early  loss  of  sexual  power  and  often  considerable  bladder  trou- 
ble.    The  disease  after  a  time  may  involve  the  arms. 

The  course  is  very  slow.  Some  cases  eventually  lose  the 
spastic  symptoms  and  knee  jerks  and  become  typical  cases  of 
locomotor  ataxia.  In  other  cases  the  paraplegia  increases,  con- 
tractures set  in,  and  the  patient  resembles  a  case  in  the  last  stage 
of  myelitis. 

Diagnosis.— The  clinical  diagnosis  is  easy  and  unmistakable. 
The  main  question  is  to  determine  whether  one  is  dealing  with 
atypical  tabes  or  some  form  of  chronic  transverse  myelitis  or 


250 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


from  a  focus  of  multiple  sclerosis.  In  myelitis  the  symptoms  come 
on  more  rapidly,  the  paraplegic  symptoms  are  more  pronounced. 
In  some  cases,  however,  a  very  good  clinical  picture  of  ataxic 
paraplegia  follows  an  attack  of  acute  myelitis.  There  are  very 
few  arm  and  no  cranial  nerve  symptoms.  In  the  tabetic  cases 
the  onset  is  slower,  there  is  more  ataxia  and  sensory  disturbance, 
and  some  eye  symptoms  are  usually  present. 

Pathological  Anatomy.— .^^  already  stated,  the  evidence  at 
present  shows  that  ataxic  paraplegia  of  the  clinical  type  described 
is  caused  by  an  extension  of  the  sclerosis  of  tabes  or  by  a  chronic 


Fig.  11:2.— Distribution  of  the  Lesion  in  Ataxic  Paraplegia  of  Myelitic  Origin. 


dorsal  myelitis.  Other  conditions  causing  transverse  pressure 
and  destruction  of  the  cord  may  cause  similar  symptoms,  but 
they  are  rare  (Figs.  112,  113). 

The  treatment  of  this  trouble  does  not  vary  greatly  from  that 
of  locomotor  ataxia  or  myelitis,  and  naturally  a  very  important 
thing  is  rest.  Under  this  treatment  I  have  seen  remarkable 
amelioration  in  every  symptom.  The  slight  anaesthesia  Avhich 
exists  can  be  made  to  disappear  by  the  use  of  electricity.  The 
trembling  and  trepidation  of  the  limbs  at  night  are  often  very 
annoying  to  the  patient.     Moderate  doses  of  bromide  relieve  this. 

I  can  strongly  recommend  the  use  of  orthopaedic  appliances 
for  giving  support  to  the  shaking  knees  and  hips.     Some  patients 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       251 

feel  better  and  are  even  improved  by  the  systematic,  careful  use 
of  the  faradic  current,  one  of  hi^h  tension  or  the  static  current 
being  preferred.  No  class  of  patients,  in  my  experience,  has  re- 
turned so  persistently  and  faithfully  for  electrical  treatment  as 
those  suffering  with  spastic  ataxia  or  spastic  paralysis.  A  thor- 
ough course  of  anti-syphilitic  treatment,  using  inunctions  and 
occasional  purges,  should  be  tried  if  needed,  and  in  later  stages 
very  large  doses  of  the  iodides  are  to  be  tried.  In  one  case,  un- 
doubtedly syphilitic,  this  certainly  did  much  good.  The  patient 
preferred  iodide  of  ammonia. 


Fig.  113.— Distribution  of  the  Lesion  in  a  Case  of  Tabetic  Origin. 

Warm  baths  and  cold  douches  are  beneficial,  but  hot  baths 
are  dangerous.  The  stomach  is  a  thing  that  must  be  attended  to 
with  great  care. 

Friedreich's  Ataxia   (Hereditary  Ataxia,  Friedreich's 
Disease,  Family  Ataxia,   Generic  Ataxia). 

Friedreich's  ataxia  is  a  chronic  degenerative  disease,  affecting 
the  several  long-fibre  systems  of  the  spinal  cord,  especially 
that  of  the  posterior  column,  and  later  those  of  the  lateral 
columns.  It  begins  in  the  lumbar  region  and  extends  up- 
ward and  downward,  finally  involving  the  medulla  and  espe- 
cially the  nuclei  of  the  hypoglossal  nerve.     It  develops  in  child- 


252  DISEASES  OF  THE  NERVOUS  SYSTEM. 

hood,  affecting  persons  with  an  imperfectly  developed  spinal  cord 
the  result  of  a  neurotic  inheritance.  Clinically  the  disease  is 
characterized  by  ataxia  beginning  in  the  lower  limbs  and  grad- 
ually involving  the  ui^per  limbs  and  the  organs  of  speech.  Cur- 
vature of  the  spine,  talipes,  vertigo,  and  finally  paralysis  and 
contractures  appear.  The  knee  jerk  is,  as  a  rule,  absent.  There 
is  but  little  pain  or  anaesthesia,  and  optic  atrophy  and  visceral 
troubles  are  usually  absent.  The  disease  is  rare,  only  about  two 
hundred  cases  being  on  record. 

Efiolfxj I/.— The  fundamental  factor  in  predisposition  is  an  in- 
herited or  connate  lack  of  development  of  the  sjDinal  cord,  more 
particularly  of  the  columns  of  Goll  and  iDyramidal  tracts.  This 
condition  is  inherited  directly  sometimes,  but  indirectly  as  a 
rule.  That  is  to  say,  the  parents  or  other  members  of  the  family 
usually  show  simply  a  neurotic  history,  and  it  is  in  only  a  minor- 
ity of  cases  that  there  is  a  history  of  ataxia  in  the  direct  line  of 
ancestry. 

The  more  frequent  condition  is  this :  the  patients  or  grand- 
parents have  some  neuroses,  such  as  insanity,  inebriety,  or  great 
nervous  irritability ;  the  ataxia  occurring  only  in  the  children  of 
one  generation.  Sometimes  in  a  single  family  the  uncles  and 
nephews  or  cousins  may  be  found  to  have  the  disease.  Hence 
the  name  "family  ataxia,"  used  by  some  writers.  There  are  a 
good  many  cases  in  which  the  parents  were  apparently  perfectly 
sound  and  healthy.  Yet  it  is  most  probable  that  the  sufferers 
from  Friedreich's  disease  inherit  a  tendency  to  degenerative  pro- 
cesses from  some  of  their  ancestors.  This  degenerative  tendency 
may  have  been  shown  in  those  ancestors  in  a  very  slight  degree. 
The  patients  rarely  have  locomotor  ataxia,  though  this  has  been 
observed  in  a  few  cases.  The  children  of  locomotor  ataxies  do 
not  have  Friedreich's  ataxia  except  in  the  very  rarest  instances. 

Syphilis  in  the  parents  is  an  element  in  some — perhajos  in 
many— cases.  Habitual  intemperance  in  parents  undoubtedly 
is  a  factor  sometimes;  much  more  rarely  consanguinity  and 
tuberculosis  act  as  predisposing  causes  of  degeneration. 

More  cases  have  been  observed  in  America  than  in  any  other 
country;  while  the  fewest  have  been  reported  from  France.  The 
disease  develops  at  about  the  time  of  jDuberty,  most  cases  occur- 
ring between  the  ages  of  six  and  fifteen  years.  It  is  not  very  rare, 
however,  for  symptoms  to  develop  even  in  infancy,  though  some 
of  the  cases  reported  at  this  time  were  probably  of  a  syphilitic 
character.  In  a  given  family  the  d,isease,  as  a  rule,  strikes  the 
older  members  first,  but  the  younger  members  are  attacked  at  a 
relatively  earlier  age.  The  most  typical  time  of  development  is 
a  rather  late  one,  i.e.,  after  twelve  years  of  age.  The  disease 
may  come  on  after  maturity.     In  American  cases  the  age  of  de- 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       253 

velopnieiit  of  the  disease  has  been  rather  earher  than  the  average. 
The  male  sex  shghtly  predominates,  its  proportion  being  about 
sixty  per  cent.  In  America  the  female  sex  has,  however,  been 
more  affected  (3  to  2).  The  patients  are  the  children  of  the  la- 
boring and  agricultural  classes.  They  have  been  found  in  the 
country  oftener  than  in  crowded  cities.  The  families  have  often 
been  large,  but  this  is  not  always  the  case,  especially  in  American 
cases.  ^S^ursing  at  the  mother's  breast  is  thought  to  have  been 
an  exciting  cause.  Usually  the  disease  appears  after  infectious 
fevers  such  as  diphtheria,  variola,  and  tyi^hoid. 

Symptoms. — The  patient  first  notices  an  uncertainty  in  the 
gait  and  some  feebleness  in  the  louver  limbs.  These  symptoms 
gradually  increase  until  they  interfere  seriously  with  progression, 
and  force  him  to  leave  off  active  work.  With  this  there  may  be 
some  slight  pains  or  numbness  in  the  lower  limbs,  and  an  exam- 
ination will  shoAv,  within  a  year  or  earlier,  that  the  knee  jerk  is 
gone.  After  five  or  six  years  the  arms  become  affected  with  inco- 
ordination, and  a  little  later  bulbar  symptoms,  such  as  thick  or 
scanning  speech,  and  often  nystagmus,  appear.  During  this  time 
the  patient  suffers  little  pain  and  has  no  trouble  with  the  bladder 
or  rectum.  Vertigo  and  headache  are  often  present  (Fig.  114). 
Dorsal  flexion  of  the  toes,  talipes  varus  or  some  other  form  of 
club-foot,  and  lateral  curvature  of  the  spine  are  often  observed. 
Oscillation  of  the  head  and  choreiform  or  inco -ordinate  move- 
ments of  the  extremities  may  develop.  As  the  disease  progresses 
the  legs  become  weaker,  and  finally  paraplegia,  with  contractures 
and  muscular  w^asting,  sets  in.  The  disease  makes  slow  progress; 
often  it  remains  almost  at  a  stand-stiil  for  years,  and  the  patients 
usually  die  of  some  inten-urrent  disease,  such  as  phthisis  or  an 
infectious  fever. 

Among  the  rarely  observed  symptoms  are  tremor,  spasms,  de- 
creased electrical  irritability,  muscular  atrophy,  vasomotor  pare- 
sis, polyuria,  glycosuria,  anaesthesia,  fibrillary  tremor,  choking 
attacks,  ptyalism,  strabismus,  diplopia,  blepharospasm,  a  slight 
degree  of  ptosis,  sluggish  pupils,  tachycardia,  profuse  sweats,  im- 
potence, slight  vesical  incontinence,  fragilitas  ossium.  Many  of 
these  symptoms  are,  however,  exceptional  and  accidental. 

The  major  and  essential  symptoms  are .  (1)  ataxia,  beginning  in 
the  lower  limbs  and  extending  to  the  arms  and  tongue;  (2)  pecul- 
iar rolling,  ataxic  gait,  ataxia  gradually  involving  the  arms;  (3) 
disturbances  of  speech ;  (4)  talipes  and  spinal  curvatures ;  (5)  grad- 
ual development  of  paraplegia  ;  (6)  loss  of  knee  jerk :  (7)  absence 
of  cutaneous  anaesthesia,  of  bladder  troubles,  of  eye  troubles  ex- 
cept nystagmus,  and  of  severe  pains;  (8)  the  development  of  the 
foregoing  at  about  the  time  of  puberty. 

Pathology.— Sixteen  autopsies  have  been  made  upon  cases  of 


254 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


Friedreich's  ataxica.     The  disease  in  most  of  the  cases  had  lasted 
over  ten  years ;  in  one,  only  two  years ;  in  two,  eight  years.     The 

examinations  have  led  to 
quite  uniform  results.  The 
lesions  of  importance  were 
found  in  the  spinal  cord 


Fig.  114.— Friedreich's  Ataxia,  Late  Fig.  115.— Showing  the  Distribu- 

Stage,  showing  curvature  of  trunk  and  de-       tion  of  the  Sclerosis  at  Dtffer- 
formities  of  le^.  ent  Levels  of  the  Cord  in  Fried- 

reich's Ataxia. 

cord  was  usually  small,  flattened,  and  apparently  congenitally 
hnperfect  in  development.  In  some  cases  two  central  canals 
have  been  seen.     A  sclerosis  exists  throughout  the  whole  length 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       255 

of  the  posterior  and  lateral  columns,  sometimes  extending  to 
the  anterior  columns  (Fig.  115).  The  sclerosis  is  most  marked 
in  the  postero-median  columns,  which  are  always  affected  in  toto. 
The  postero-external  column  is  less  involved,  and  there  is  often 
a  narrow  strip  of  healthy  tissue  between  the  posterior  horn  and 
the  sclerosed  area,  also  between  the  posterior  gray  commissure 
and  the  diseased  i>arts.  The  posterior  column  sclerosis  is  usually 
most  marked  in  the  lumbar  region.  In  the  lateral  columns  the 
sclerosis  always  affects  the  crossed  pyramidal  tracts.  The  direct 
cerebellar  tracts  and  the  so-called  ascending  antero-lateral  tract 
are  diseased  in  some  cases,  but  apparently  not  in  all.  In  a  few 
instances  the  anterior  median  columns  are  involved.  A  zone  of 
healthy  tissue  is  often  found  between  the  sclerosed  pyramidal 
tracts  and  the  posterior  horn. 

There  are  no  important  changes  in  the  gray  matter. 

Some  chronic  lei^tomeningitis,  esiDecially  on  the  posterior  sur- 
face, has  been  noted.  The  medulla  shows  some  traces  of  exten- 
sion of  the  sclerosis,  but  the  involvement  of  the  cells  of  the  hypo- 
glossal nucleus  is  probably  the  most  significant  change.  The 
brain  exhibits  no  changes  of  importance  in  relation  to  the  symp- 
tomatology of  the  disease.  The  posterior  nerve  roots  are  exten- 
sively sclerosed,  the  anterior  roots  less  so,  and  the  peripheral 
nerves  show  some  degenerative  changes. 

It  is  thought  by  some  (Dej^rine)  that  the  peripheral  nerves 
are  much  less  involved  than  in  tabes  dorsalis.  It  is  also  asserted 
that  the  sclerosis  in  the  cord  is  really  a  neuroglia  proliferation — 
a  gliosis.  Others  assert  that  Friedreich's  ataxia  is  a  primary  de- 
generative disease  of  the  spinal  vessels,  and  that  the  nervous  tis- 
sue is  secondarily  involved. 

Course  and  Prognosis. — The  disease  is  a  progressive  one, 
though  it  may  be  stationary  for  a  long  time,  and  may  even  show 
temporary  improvement.  The  longest  period  of  duration  of  the 
disease  on  record  is  forty-six  years  and  the  shortest  two  years, 
the  average  being  fifteen  or  twenty  years.  Death  occurs  from 
some  intercurrent  disorder. 

Treatment.— A.  quiet  life,  good  food,  and  favorable  hygienic 
surroundings  are  the  main  therapeutic  helps.  Arsenic  and  vari- 
ous nerve  tonics  may  be  of  temporary  benefit.  My  cases  and 
some  of  the  French  cases  were  benefited  by  suspension  by  the 
neck  in  a  Sayre  apparatus.  If  the  disease  appears  in  one  mem- 
ber of  a  family,  effort  should  be  made  to  prevent  its  appearance 
in  others.  The  infant  should  not  be  nursed  by  its  mother;  spe- 
cial care  should  be  taken  to  prevent  its  getting  any  infectious 
fevers  and  to  prevent  it  from  receiving  any  falls  or  blows.  Its 
life  should  be  exceptionally  quiet,  so  far  as  physical  exertion  goes. 

Hereditary  Ataxic  Paraplegia.— There  is  a  primary  de- 


256  DISEASES   OF   THE   NERVOUS   SYSTEM. 

generative  disorder  of  the  spinal  cord  occurring  in  children,  and 
characterized  by  symptoms  of  ataxia  with  some  cutaneous  anes- 
thesia and  spasm.  The  disease  develops  usually  about  the 
time  of  puberty.  It  progresses  slowly,  and  takes  upon  itself  the 
characters  such  as  have  been  described  under  the  name  Ataxic 
Paraplegia.  Such  cases  may  for  a  time  be  considered  of  func- 
tional or  hysterical  character.  A  longer  acquaintance  with  them, 
however,  reveals  the  progressive  and  organic  character  of  the 
disease. 

Hereditary  ataxic  paraplegia  belongs  to  the  same  group  as 
Friedreich's  ataxia.  It  is  a  primary  degenerative  disorder,  in- 
volving, no  doubt,  the  lateral  and  posterior  columns  of  the  spinal 
cord,  but  with  a  preponderance  of  the  lesion  in  the  lateral  col- 
unms.  The  symptoms  resemble  those  of  ataxic  paraplegia,  but 
the  jjrogress  is  very  slow.  Cases  have  been  described  by  Dr. 
Charles  H.  Brown. 

Combined  Sclerosis  with  Terminal  Softening. 

This  is  a  rare  disease,  described  by  Dr.  J.  J.  Putnam  and  later 
bj'-  myself.  It  is  a  rather  rapidly  progressive  sclerosis  of  the  cord, 
ending  in  a  softening  which  may  be  due  to  tubercular  or  other 
secondary  infection. 

Etiology.— The  patients  are  in  most  cases  women.  The  ages 
range  from  forty-five  to  sixty-four  years.  In  some  there  is  a 
neurotic  inheritance,  and  in  several  lead  has  been  found  in  the 
urine  at  times.  No  distinct  history  of  syphilis  has  been  made 
out  in  any  instance,  nor  are  the  patients  alcoholic. 

The  disease  runs  a  rather  rapid  course,  varying  from  nine 
months  to  four  years  and  averaging  two  years. 

Syuiptoms. — The  symptoms  begin  generally  with  numbness  of 
the  extremities,  followed  by  progressive  enfeeblement,  and  end- 
ing always  in  a  paraplegia.  Grreat  emaciation  and  anaemia  are 
present,  and  there  is  often  an  obstinate  diarrhoea.  No  x:>araly- 
sis  of  any  special  grouj^s  of  muscles  occurs  until  the  final  para- 
plegia sets  in.  There  are  in  some  cases  anaesthesia  and  ataxia, 
but  spastic  symptoms,  with  exaggerated  knee  jerk  and  ankle 
clonus,  are  the  more  common.  Lancinating  or  girdle  pains  are 
very  rare.  The  arms  are  affected,  but  less  than  the  legs.  The 
vision  and  other  special  senses  and  speech  are  not  disturbed. 
Mental  symptoms  approaching  dementia  occur  in  the  terminal 
stages  in  some  cases. 

The  general  course  is  that  of  a  rather  rapidly  progressive 
affection  causing  pariesthesia  and  sometimes  anaesthesia  of  the 
extremities,  especially  the  lower,  with  progressive  weakness  of 
the  extremities.  This  is  associated  with  anaemia,  general  mus- 
cular emaciation,  diarrhoea,  ending  in  a  paraplegia. 

Pathological  Anatomi/.— The  pathological  appearances  of  the 
spinal  cord  as  described  by  Putnam  correspond  to  my  own  ob- 
servations: in  all  the  cases  two  sets  of  changes  in  the  cord  are 
recognizable,  one  of  older  date,  consisting  in  a  relatively  dense 
sclerosis  in  the  posterior  columns  and  in  the  lateral  colunni 
(mainly  confined  to  the  pyramid  tracts);   and  one  of  subacute 


DEGENERATIVE   DISEASES   OF  THE   SPINAL   CORD.       257 

character,  and  evidently  of  quite  recent  occurrence.  This  sub- 
acute process  is,  as  regards  tlie  white  columns,  pp^rtly  in  new 
tracts,  partly  around  the  borders  of  the  more  dense  sclerosis,  and 
is  chiefly  characterized  by  the  peculiar  perforated  appearance 
which  indicates  a  somewhat  rapid  destruction  of  nerve  tubes, 
with  the  oedematous  distention  or  destruction  of  the  intervening 
septa,  associated  with  the  formation  of  granule  cells. 

In  the  gray  horns  the  degenerative  change  (partly  recent, 
partly  of  older  date)  is  indicated  by  a  disintegration  of  nerve 
cells. 

The  prognosis  is  unfavorable. 

The  treatment  is  purely  sustaining  and  symptomatic. 

Spastic  Spijval  Paralysis,   Hypertonic  Paralysis,  Spas- 
tic Paraplegia  (Primary  Lateral  Sclerosis). 

Definition. — Spastic  spinal  paralysis  is  a  disease  characterized 
by  rigidity  and  weakness  of  the  limbs,  especially  the  lower,  with- 
out muscular  atrophy  and  with  little  sensory  disturbance. 

The  disease  is  described  here  because  it  has  always  been  called 
a  "primary  lateral  sclerosis."  No  autopsy  has  as  yet,  however, 
proved  that  such  a  condition  exists,  and  this  name  had  best  be 
dropped. 

Etiology. — Spastic  spinal  paralysis  must  be  considered  simply 
a  symptom-complex  due  to  various  causes.  The  principal  ones 
are:  1,  chronic  dorsal  myelitis  in  adults;  2,  double  cerebral  hem- 
iplegia in  children ;  and,  3,  a  functional  cause  of  unknown  char- 
acter.    Rarer  causes  are  multiple  sclerosis  and  spinal  tumor. 

In  adults  the  causes  of  spinal  syphilis  and  myelitis  are  nat- 
urally the  causes  of  this  disease.  In  children  the  brain  lesions  of 
hemiplegia  and  Pott's  disease  are  causes.  The  functional  and 
curable  form  occurs  oftener  in  men  and  is  due  to  exposures,  over- 
exertion, or  other  influences,  often  perhaps  of  a  specific  charac- 
ter. 

Symptoms. — The  general  character  of  the  symptoms  is  that 
of  a  slowly  developing  paraplegia  with  excessive  stiffness  of  the 
lower  limbs.  The  reflexes  are  greatly  exaggerated,  clonic  and 
tonic  spasms  occur,  forming  what  is  known  as  spinal  trepidation 
or  epilepsy.  The  muscles  feel  hard  and  do  not  waste ;  they  may 
even  be  slightly  hypertrophied.  The  electrical  reactions  are  not 
notably  changed.  The  gait  is  peculiar.  The  patient  takes  short 
steps,  pushing  the  feet  along,  and  the  toes  cling  to  the  ground. 
There  is  a  sense  of  weariness  and  numbness  in  the  limbs,  but 
rarely  any  anaesthesia  or  pain.  The  bladder  and  sexual  func- 
tions are  usually  somewhat  involved,  and  constipation  occurs. 

Later  in  the  disease  the  arms  may  be  affected,  and  in  rare 
cases  there  is  involvement  of  the  trunk  muscles.  The  cranial 
nerves  are  rarely  reached,  but  sometimes  an  excessive  irritability 
17 


258  DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  the  muscles  of  mastication  occurs,  and  a  tap  on  the  chin  causes 
an  abnormally  quick  spasmodic  contraction  or  "  chin  jerk."  In 
children  there  is  rather  less  reflex  irritability,  but  a  greater  ten- 
dency to  contractures  and  deformities. 

Course  and  Prognosis. — The  disease,  if  organic,  runs  a  very 
long  course  and  has  little  tendency  to  shorten  life.  The  ordinary 
forms  are  not  curable,  but  their  progress  may  be  stopped  and 
improvement  occur.  In  the  functional  forms  a  cure  may  take 
place.     I  have  observed  it  to  do  so  in  a  few  months. 

The  pathological  anatomy  is  that  of  the  diseases  already  men- 
tioned. In  dorsal  myelitis  there  occurs  a  descending  degeneration 
of  the  pyramidal  tracts.  The  anterior  cornual  cells  are  cut  off 
from  the  inhibitory  influence  of  the  brain,  and  hence  the  spasm. 
On  the  other  hand,  these  cells  in  the  lower  part  of  the  cord  are 
not  diseased,  and  hence  there  is  no  muscular  atrophy.  In  double 
cerebral  hemiplegia  there  is  a  descending  degeneration  from  the 
brain  along  the  direct  and  crossed  pyramidal  tracts. 

The  pathology  of  the  functional  cases  is  unknown:  some  of 
them  may  be  of  infectious  or  toxic  origin,  and  the  anatomical 
condition  may  be  an  exudative  dorsal  myelitis. 

The  diagnosis  of  the  clinical  type  is  easy.  It  depends  on  the 
existence  of  moderate  paraplegia  with  spasm  and  exaggerated 
reflexes,  without  muscular  atrophy  or  sensory  disturbance. 
The  special  primary  cause  is  often  more  difficult  to  determine. 
It  is  especially  important  to  examine  for  Pott's  disease,  to  ex- 
clude hysteria  and  amj'otrophic  lateral  sclerosis.  In  Pott's  dis- 
ease there  is  usually  pain,  tenderness,  and  deformity.  In  hyster- 
ical paraplegia  it  is  doubtful  if  there  is  ever  true  ankle  or  rectus 
clonus  (Gowers).  Besides,  in  hysteria  the  paralysis  has  a  more 
acute  onset  and  different  course.  In  amyotrophic  lateral  scle- 
rosis muscular  atrophy  soon  apijears.  In  multiple  sclerosis  evi- 
dences of  sclerotic  foci  in  the  bulb  and  brain  appear. 

The  chronic  onset  of  the  disease  distinguishes  it  from  hemor- 
rhages, acute  softenings,  and  injuries. 

The  functional  form  called  by  Bastian  hypertonic: paralysis 
is  of  rather  acute  onset  and  attended  with  severer  symptoms  of 
motor  irritation.  The  weakness  in  the  legs  may  be  for  a  time 
very  great,  and  profuse  sweating  sometimes  occurs. 

Treat}nent.— This  must  be  directed  to  the  cause.  In  syphilitic 
cases  iodide  of  potassium  and  mercury  are  to  be  given.  AVarm 
biths,  Turkish  baths,  massage,  and  galvanism  are  recommended. 
In  my  experience  electrical  currents  of  high  tension,  static  sparks, 
and  the  secondary  coil  have  been  most  useful,  though  they  are 
condemned  by  some.  Some  patients  feel  better  while  standing, 
and  they  like  Avo)-k  at  a  bench  or  counter.  Grymnastic  exercises, 
bicycle-riding,  and  orthopedic  measures  help  children  and  very 


DEGENERATIVE   DISEASES   OF  THE   SPINAL  CORD.       259 

chronic  cases  in  adults.  Arsenic,  strychnine  in  quite  small  doses 
(gr.  Y^o),  and  the  bromides  sometimes  give  relief.  Suspension  is 
not  often  of  value,  and  may  do  harm. 


Secondary  Degeneratiot^s  of  the  Spinal  Cord. 

When  any  of  the  long-fibre  tracts  of  the  cord  are  cut  across 
or  destroyed,  there  soon  results  a  degeneration.     This  extends 


Fig.  116.— Showing  the  Tracts  Affected  in  Secondary  Degenerations  of  the 
Spinal  Cord  in  Lesions  at  Different  Levels.  1,  Descending  degeneration  after 
lesion  at  sixth  cervical ;  2,  ascending  and  descending  degeneration,  lesion  at  sixth 
dorsal ;  3,  ascending  and  descending  degeneration,lesion  at  twelfth  dorsal ;  4,  ascend- 
ing degeneration,  lesion  at  first  sacral. 

up  or  down  in  accordance  with  the  direction  in  which  the  tracts 
carry  impulses.  Thus  when  the  crossed  pyramidal  tract  is  cut 
across  the  degeneration  extends  down ;  when  the  column  of  Groll 
is  involved  it  extends  up.  The  degenerative  process  begins  al- 
most immediately  and  is  complete  in  a  few  weeks.  The  myelin 
sheath  swells,  gradually  breaks  up  and  disintegrates;  the  axis 
cylinder  is  involved  next.     At  the  same  time  the  connective  tissue 


260  DISEASES   OF  THE   NERVOUS   SYSTEM. 

proliferates  and  takes  the  place  of  the  wasted  nerves.  Finally, 
long  tracts  of  connective  tissue  have  taken  the  place  of  the  nerve 
tissue.  The  process  may  not  be  a  complete  one  if  the  lesion  does 
not  entirely  destroy  the  tract.  The  short-fibre  tracts  degenerate 
only  a  little  way  up  and  down  (Fig.  116). 

Secondary  degenerations  complicate  and  add  to  the  patholog- 
ical change  in  all  organic  diseases  of  the  cord.  In  brain  disease, 
involving  the  motor  tract,  as  in  hemiplegia,  secondary  degenera- 
tion extends  into  the  cord  and  adds  to  the  seriousness  of  the  dis- 
ease. Degenerations  of  the  spinal  cord,  however,  do  not  extend 
up  to  the  brain  except  in  the  case  of  disease  of  the  cerebellar 
tracts. 

The  accompanying  figures  show  the  extent  of  the  secondary 
degeneration  in  total  transverse  lesions  of  the  spinal  cord  at  dif- 
ferent levels.  There  is  still  some  doubt  as  to  the  degeneration 
of  the  antero-lateral  ascending  tract,  which  some  (Mott)  assert  is 
part  of  the  cerebellar  tract  and  goes  to  the  vermis. 


CHAPTEE   XIV. 


THE   PROGRESSIVE   MUSCULAR  ATROPHIES   AND 
MUSCULAR  DYSTROPHIES. 

The  result  of  modern  studies  is  to  show  that  the  anterior  cor- 
nual  cells  of  the  spinal  cord,  the  motor  nerves  and  their  terminal 
end-organs,  the  muscles,  form  a  trophic  unit,  and  that  the  same 
degenerative  disease  may  attack  either  end  or  any  part  of  this 
physiological  mechanism.  There  is  a  clinical  and  pathological 
unity  in  all  the  different  spinal  and  muscular  types  of  atrophies. 


1.  2. 

Fig.  117.— Showing  :  1,  Segment  of  spinal  cord  with  anterior  Jiorn  cell,  end-brush, 
and  lateral  tracts,  the  parts  affected  in  progressive  muscular  atrophies  ;  and,  2,  the 
muscle  and  its  nerves,  the  parts  affected  in  progressive  muscular  dystrophies. 

I5ut  there  are  sufficient  differences,  also,  to  oblige  us  for  conven- 
ience' sake  to  make  certain  classifications.  Thus  those  disorders 
which  attack  chiefly  and  first  the  anterior  horn  cells  and  the 
I)yramidal  tract  are  called  progressive  muscular  atrophies; 
those  disorders  attacking  first  the  muscle  tissue  and  its  nerves 
are  caXVed  progressive  muscular  dystrophies  (Fig.  117).  The  pro- 
gressive muscular  atrophies  of  central  origin  may  attack  the  mo- 
tor nerve  cells  of  the  eye,  of  the  throat  and  lips,  of  the  upper  or 
lower  spinal  cord.  In  accordance  with  the  level  affected  the  dis- 
ease has  received  a  different  name.  Sometimes  the  pyramidal 
tracts  of  the  spinal  cord  are  first  and  most  involved.  This  has  fur- 
nished excuse  for  another  type.  Then,  again,  while  most  cases 
of  the  muscular  atrophy  are  acquired,  there  is  one  type  of  it 
which  is  a  hereditary  one.  Thus  we  find  the  disease  classified  as 
follows . 


262  DISEASES   OF   THE   NERVOUS   SYSTEM. 

f  Progressive  ophthalmoi^legia. 
Progr  e  s  s  i  V  e  m  u  s-  I  Progressive  bulbar  palsy, 
cular  atrophies  of  I  Progressive  muscular  atrophy  (arm  type). 
central  or  nervous]  Progressive  hereditary  muscular  atrophy 
origin.  |      (leg  type). 

t  Amyotrophic  lateral  sclerosis. 

The  progressive  muscular  dystrophies  have  also  been  much 
subdivided,  but  they  are  essentially  the  same  disease,  as  will  be 
seen  later. 

Of  the  muscular  atrophies,  I  have  already  described  ophthal- 
moplegia. Beginning  from  above  I  will  describe  here  bulbar 
paralysis,  for  though  anatomically  it  belongs  to  disease  of  the 
brain,  pathologically  and  clinically  it  belongs  to  the  cord. 


Glosso-Labio-Laryxgeal  Paralysis  (Progressive  Bulbar 
Paralysis). 

This  is  a  disease  characterized  by  progressive  wasting  and 
paralysis  of  the  muscles  of  the  tongue,  lips,  palate,  and  throat, 
due  to  an  atrophy  of  the  nuclei  of  the  nerves  supplying  those 
l>arts. 

Etiology.— It  is  a  disease  of  the  degenerative,  period  of  life, 
most  cases  occurring  after  forty  and  between  that  time  and  sev- 
enty. It  occurs  rather  oftener  in  men  than  women.  A  neurotic 
heredity  is  sometimes  noted.  Exposure  to  cold  and  excessive 
use  of  the  muscles,  mental  strain,  debilitating  influences,  lead, 
and  syphilis  are  causal  factors. 

Symptoms. — The  tongue  is  the  part  first  affected.  The  patient 
speaks  indistinctly  and  cannot  articulate  the  lingual  consonants 
/,  V,  11,  and  t.  The  tongue  cannot  be  elevated  and  is  protruded 
only  a  little  distance.  It  looks  scarred  and  wrinkled.  The  lips 
become  weak  and  the  patient  cannot  whistle  nor  make  the  con- 
sonants p,  &,  m  or  the  vowel  o.  The  saliva  begins  to  dribble 
from  the  mouth.  Disturbance  in  swallowing  soon  develops. 
Hard  solids  are  taken  with  difficulty,  next  fluids,  while  semi-sol- 
ids are  generally  managed  best.  The  lips  finally  become  so  para- 
lyzed that  the  mouth  cannot  be  shut,  and  the  lower  part  of  the 
face  is  motionless  and  expressionless.  The  upper  face  wears  an  ex- 
pression of  anxiety  and  suffering,  the  saliva  dribbles  constantl5% 
and  the  whole  physiognomy  of  the  patient  becomes  characteristic 
and  pitiful  in  the  extreme.  The  facial  nerve  may  get  some- 
what involved.  Articulation  becomes  almost  entirely  lost;  the 
voice  has  a  nasal  twang  from  paralysis  of  the  palate. 

The  patient  has  tired  and  uncomfortable  sensations  of  dryness 
and  stiffness  about  the  throat.     There  is  no  pain  or  anaesthesia, 


MUSCULAR    ATROPHIES   AND   DYSTROPHIES.  263 

but  occasionally  there  is  impairment  of  the  sense  of  taste.  The 
throat  reflex  is  usually  lost,  so  that  tickling  it  causes  no  reaction. 

Electric  irritability  is  at  first  unchanged,  but  in  the  later 
stages  partial  degeneration  reaction  occurs.  In  rare  cases  there 
is  a  rapid  pulse  and  still  more  rarely  glycosuria. 

The  laryngeal  reflex  becomes  weak,  the  adductors  also,  but 
abductor  paralysis  is  rare. 

The  mind  is  not  affected,  but  there  is  often  an  emotional 
weakness  and  tendency  to  tears — not  entirely  unreasonable  in 
view  of  the  distressing  nature  of  the  malady. 

The  disease  is  often  the  terminal  stage  of  spinal  muscular 
atrophy ;  it  may  be  associated  with  the  latter,  witii  amyotrophic 
lateral  sclerosis  or  with  ophthalmoplegia.  All  these  types  may 
occur  together. 

It  runs  a  progressive  course,  with  remissions  of  a  few  weeks  or 
months.  It  lasts  from  one  to  three  or  four  years.  In  one  case 
it  has  lasted  seven  years. 

The  termination  is  eventually  fatal.  Death  occurs  through  in- 
terference with  swallowing,  and  inanition  or  a  broncho-pneu- 
monia or  bronchitis  may  develop  which  ends  the  patient's  life. 

Pathology. — The  primary  lesion  is  found  in  the  nuclei  of  ori- 
gin of  the  hypo-glossal,  glosso-pharyngeal,  vagus,  and  spinal 
accessory  nerves.  The  raphe  fibres  and  the  anterior  pyramids 
are  also  usually  somewhat  involved.  There  is  sometimes  atrophy 
of  the  cells  of  the  facial  nerve  and  of  the  nucleus  ambiguous, 
which  is  the  motor  nucleus  of  the  vagus.  The  brunt  of  the 
disease  falls,  therefore,  upon  those  more  superficial  or  posterior 
nuclei  which  are  representative  of  a  continuation  of  the  anterior 
cornual  cells.  If  the  disease  is  complicated  with  amyotrophic 
lateral  sclerosis,  or  progressive  muscular  atrophy,  or  ophthalmo- 
plegia, we  find  atrophy  in  the  cord  or  ocular  nuclei.  The  atro- 
phic process  is  similar  to  that  observed  in  the  spinal  disease. 

The  muscles  of  the  tongue,  and  to  a  less  extent  of  the  orbicu- 
laris oris  and  throat,  show  evidences  of  degeneration  and  atrophy. 
In  some  cases  the  tongue  is  not  shrivelled,  owing  to  the  presence 
of  a  fatty  deposit,  and  on  account  of  this  the  disease  has  been 
divided  into  atrophic  and  paralytic  types,  but  this  distinction  is 
unnecessary.  A  few  cases  have  occurred  in  which  no  bulbar 
lesion  was  discoverable,  even  by  the  microscope.  In  these  cases 
the  disease  lay  probably  in  the  brain  or  peripheral  nerves. 

Diagnosis.— Th-e  disease  must  be  distinguished  from  polio- 
encephalitis inferior,  bulbar  apoplexy,  tumors,  and  softening, 
from  multiple  sclerosis,  and  from  chronic  lesions  of  the  cerebral 
hemispheres  causing  pseudo-bulbar  paralysis.  The  slow  onset, 
the  progressive  course,  the  bilateral  character,  the  absence  of  in- 
volvement of  sensory  nerves,  and  the  degenerative  reactions  are 


264  DISEASES   OF  THE   NERVOUS   SYSTEM. 

always  siifficjent  for  a  diagnosis.  It  is  important  always  to  note 
whether  there  is  ophthalmoplegia  and  spinal  muscular  atrophy 
associated  with  the  disease. 

Treatment.— T\\e  patient  should  be  kept  quiet;  he  must  be 
overfed  and  given  massage  and  electricity  in  moderation.  The 
same  drug  treatment  as  in  the  spinal  disease  is  indicated.  Small 
doses  of  morphine,  gr.  2V  to  3^,  and  of  atropine  may  be  given  also. 
Electricity  should  be  tried  for  a  short  time  twice  or  even  thrice 
daily,  if  possible.  The  faradic  current  may  be  used,  alternating 
or  combined  with  the  galvanic.  Galvanization  of  the  neck  and 
medulla  appears  to  do  no  good.  After  a  time  it  may  be  neces- 
sary to  feed  with  a  tube  or  even  to  do  tracheotomy. 

Progressive  Muscular  Atrophy  (Progressive  Spinal 
Amyotrophy  ;  DucHE:NNE-ARA2f 's  Disease). 

This  is  a  disease  characterized  by  a  slow,  progressive  muscular 
atrophy  of  the  muscles  of  the  extremities  and  trunk,  with  conse- 
quent paralysis,  not  accompanied  with  any  notable  sensory  dis- 
turbance, and  due  to  a  progressive  atrophy  of  the  motor  and 
trophic  cells  in  the  spinal  cord. 

Etiology. — The  disease  affects  persons  in  the  middle  period  of 
life  (twenty-five  to  forty-five).  The  extremes  are  fourteen  and 
seventy  years  (Gowers).  It  is  more  frequent  in  males.  Heredity 
is  rarely,  if  ever,  a  factor.  Great  mental  strain,  exposure,  trau- 
matism, excessive  use  of  certain  groups  of  muscles,  acute  infec- 
tious diseases — especially  typhoid,  measles,  cholera— child-birth, 
acute  rheumatism,  syphilis,  and,  more  than  anything  else,  lead- 
poisoning  are  causes.  It  may  complicate  locomotor  ataxia.  The 
causes,  as  may  be  seen,  are  much  the  same  as  those  of  bulbar 
paralysis. 

Symptoms.— The  patient  suffers  at  first  from  slight  rheuma- 
toid pains  in  the  shoulder  or  arm,  associated  with  some  feelings 
of  numbness  and  weariness.  Muscular  Avasting  then  begins  to 
appear,  and  usually  in  one  hand.  The  adductor  longus  pollicis  is 
very  early  affected,  also  the  thenar  muscles  and  the  interossei. 
The  atrophy  spreads  from  muscle  to  muscle,  and  does  not  follow 
the  distribution  of  nerves,  although  the  ulnar  nerve  supply  is 
most  seriously  disordered.  The  ball  of  the  thumb  becomes  flat- 
tened, and  the  patient  cannot  abduct  or  flex  it  well.  When  the 
radial  interossei  are  reached  the  forefinger  cannot  be  abducted, 
and  this  is  often  an  early  sign.  The  disease  gradually  extends 
upward,  attacking  the  flexors  and  extensors  of  the  forearm,  then 
the  upper  arm  and  shoulder.  Meanwhile  the  hand  has  become 
thin  and  flattened,  flexion  of  wrist  and  extension  of  flngers  are 
lost,  and  a  characteristic  "  griffin-claw  "  appearance  results.    Mean- 


'/ 


MUSCULAR   ATROPHIES  AND   DYSTROPHIES.  265 

while  (three  to  nine  months)  the  other  arm  begins  to  be  affected. 
Occasionally  there  is  a  remit-sion  for  a  time. 

In  a  few  cases  the  atrophy  begins  first  in  the  shoulders  and 
arm,  attacking  the  deltoid,  biceps,  and  triceps,  then  extending 
downward  to  the  hands.     This  constitutes  the  "  upper-arm  type." 

If,  as  is  usually  the  case,  the  disease  continues  to  progress,  it 
passes  from  the  shoulder  girdle  to  the  deep  muscles  of  the  back, 
then  downward,  involving  successively  the  hip  and  thigh  mus- 
cles, the  glutei,  the  crural  extensors  and  abductors  being  oftenest 
chosen.  The  leg  muscles  may  be  finally  involved,  but  they  usu- 
ally escape.  The  disease  as  it  descends  continues  its  progress  in 
the  trunk,  involving  the  intercostals.  It  slowly  ascends  the  neck 
also,  and  finally  leads  to  paralysis  of  the  diaphragm,  or  a  bulbar 
palsy  may  set  in. 

It  will  be  seen  that  the  ordinary  course  of  the  disease  is  from 
the  lower-arm-muscle  groups  (ulnar  and  median)  up  to  the  shoul- 
der group  (middle  cervical  nerves),  then  down  through  the  dorsal 
and  lumbar  nerves,  rarely  reaching  the  sacral  groups.  In  very 
rare  cases  it  begins  in  the  legs  and  ascends. 
y  Along  with  the  wasting  there  is  a  corresponding  weakness  and 
^ ^  paralysis,  but  the  paralysis  is  the  result  of  the  atrophy  and  does 
not  precede  it.  Fibrillary  twitchings  of  the  muscles  occur;  the 
idiopathic  muscular  contraction  caused  by  striking  it  a  blow  is 
very  marked ;  myoid  tumors  are  easily  brought  out.  In  some  cases 
the  muscles  are  flaccid  and  toneless,  and  the  deep  reflexes,  knee 
jerk,  and  arm  jerk  disappear  early  (atonic  atrophy),  but  in  other 
cases  the  rigidity  and  tonicity  of  the  muscles  are  increased,  the 
knee  jerks  exaggerated,  and  we  have  tonic  atrophy.  This  con- 
dition may  be  so  marked  as  to  give  rise  to  a  special  clinical  type 
of  progressive  atrophy  known  as  amyotrovhicJ,ateral  scleros is. 

The  electrical  irritability  of  the  muscles  lessens  to  both  gal- 
vanic and  faradic  currents,  but  no  marked  qualitative  changes 
occur  at  first.  Eventually  we  may  get  partial  degeneration  reac- 
tions, but  these  occur  late  in  the  disease,  unless  this  runs  a  very 
rapid  course,  when  fairly  typical  degeneration  reactions  may  be 
got.  A  peculiar  contraction  of  the  uj)per  limbs  is  sometimes  pro- 
duced by  placing  the  negative  pole  of  the  galvanic  battery  over 
the  fifth  cervical  vertebra,  and  the  positive  in  the  triangle  just 
below  the  lower  jaw  (diplegic  contraction  of  Remak).  A  peculiar 
palmar  spasm  is  described  by  Voeter,  caused  by  suddenly  inter- 
rupting a  faradic  or  galvanic  current  passed  along  the  affected  arm. 

In  typical  cases  of  progressive  muscular  atrophy  there  is  no 
anaesthesia;  and  when  such  symptoms  develop,  the  presence  of 
jjeripheral  disease  or  of  syringo-myelia  or  spinal  tumor  must  be 
expected.  The  patients  may  suffer  from  rheumatic-like  pains 
and  from  parsesthesiae. 


266  DISEASES   OF  THE   NERVOUS   SYSTEM. 

The  affected  pan'ts  often  show  excessive  sAveating  and  con- 
gestion and  evidence  of  vasomotor  disturbance.  This  may  in- 
volve the  face  on  one  or  both  sides;  one  pupil  may  be  larger 
than  the  other,  due  to  irritation  of  the  ciho-spinal  centre.  The 
u'is-reflex,  however,  is  preserved,  and  the  optic  nerve  is  never  in- 
volved. 

The  sexual  power  is  often  weakened,  but  the  sphincters  are 
not  attacked.  The  urine  shows  variations  in  the  amount  of  urea. 
There  is  usually  an  increase  of  lime  salts. 

Complications. — The  most  common  complication  is  an  exten- 
sion of  the  process  to  the  medulla,  causing  disturbance  of  speech 
and  swallowing.  Muscular  atrophy  eompUcates  locomotor  ataxia, 
but  is  rarely  complicated  by  it.  A  high  degree  of  spasm  and 
rigidity  of  the  legs,  particularly,  may  occur,  causing  the  condition 
known  as  amyotrophic  lateral  sclerosis. 

Course  and  Duration. — The  disease  usually  progresses  stead- 
11}'^  until  it  has  reached  an  advanced  stage,  when  it  may  stop. 
Remissions  may  occur  earlier,  however,  and  even  some  improve- 
ment take  place ;  the  disease  then  ordinarily  jjrogresses  again.  It 
lasts  from  two  years  to  thirty  or  more,  but  on  the  average  not 
over  ten  or  twelve  years.  Death  usually  occurs  from  i^ulmonary 
disease,  owing  to  the  weakness  of  the  respiratory  muscles.  Some- 
times the  extension  to  the  medulla  and  involvement  of  the  mus- 
cles of  deglutition  and  of  the  larynx  is  the  cause  of  death. 

Pathology. — The  primary  anatomical  change  is  a  degenera- 
tive atrophy  of  the  cells  of  the  central  parts  and  anterior  horns 
of  the  gray  matter  of  the  spinal  cord.  The  atrophy  gradually 
extends  and  involves  the  whole  anterior  horn.  It  also  extends 
vertically,  first  down,  then  up.  Along  with  this  atrophy  are 
degenerative  changes  in  the  lateral  columns  ;  consecutive  to 
this  there  is  atrophy  of  the  anterior  roots,  peripheral  nerves, 
and  the  muscles.  The  disease  begins  in  the  deeper  parts  of 
the  anterior  cornua,  involving  the  central  and  median  groups 
of  cells.  These  are  more  concerned  in  nutrition  and  in  the  finer 
muscular  movements  of  the  extremities.  Hence  atrophy  alwa3's 
precedes,  or  at  least  keeps  pace  with,  paralysis.  The  levels  af- 
fected are  the  lower  cervical  and  upper  dorsal;  but  if  the  dis- 
ease is  extensive,  the  dorsal,  lumbar,  and  sacral  cord  are  also  in- 
volved. The  affected  part  is  nearly  free  from  nerve  cells,  and 
those  present  are  atrophied,  their  processes  are  short  or  absent, 
and  the  cell  has  lost  its  angular  appearance.  Sclerotic  and  pig- 
mentary changes  are  observed.  The  neuroglia  and  connective- 
tissue  cells  are  increased  in  number,  but  there  are  no  marked 
changes  in  the  blood-vessels,  though  these  may  be  much  dilated. 
There  is  always  some  degeneration  of  the  lateral  columns,  and 
this  may  be  very  complete.     It  is  confined  chiefly  to  the  j)yra- 


MUSCULAR   ATROPHIES   AND   DYSTROPHIES.  267 

midal  tracts,  but  extends  somewhat  anteriorly  into  the  mixed 
lateral  column.  It  does  not  affect  the  cerebellar  or  ascending 
lateral  tracts.  The  degeneration  has  been  traced  up  into  the 
brain  as  far  as  the  internal  capsule  and  ev^en  to  the  cortex.  The 
anterior  columns  may  be  slightly  affected .  The  posterior  horns, 
columns,  and  roots  are  normal. 

The  affected  muscles  show  various  degrees  of  degeneration. 
They  are  pale  and  streaked  with  yellow  due  to  fatty  deposits. 
Some  fibres  may  be  simplj'  narrow  and  shrunken,  others  have 
lost  their  striatlon  and  become  granular  from  deposit  of  fat 
globules  or  degenerated  muscle  elements.  Other  fibres  have  lost 
their  striations  and  look  as  if  filled  with  a  homogeneous,  glassy- 
looking  substance  containing  a  few  fat  granules  (vitreous  degen- 
eration); others  show  a  longitudinal  striation.  The  interstitial 
connective  tissue  is  increased  and  in  places  has  taken  the  place 
entirely  of  the  muscles.  The  capillaries  and  small  vessels  are 
distended.  Healthy  fibres  may  be  seen  among  the  diseased. 
Changes  have  been  found  in  the  sympathetic  nervous  system, 
but  they  are  unimportant. 

The  diagnosis  has  to  be  made  from  the  progressive  muscular 
dystrophies,  chronic  poliomyelitis  anterior,  syringo-myelia,  neu- 
ritis, and  neuritic  fauuly  atroph5^ 

In  the  muscular  dystrophies  there  is  commonly  a  history  of 
heredity;  the  disease  begins  usually  in  childhood  or  adolescence. 
It  attacks  the  lower  limbs  oftener ;  it  is  slower  in  progress ;  there 
are  no  fibrillary  contractions,  and  the  degeneration  reaction  does 
not  occur. 

Chronic  poliomyelitis  anterior  begins  suddenly  and,  having 
reached  its  height,  does  not  progress,  but  remains  stationary  or 
improves.  The  paralysis  occurs  first,  the  wasting  follows.  It 
affects  groups  of  muscles  physiologically  related,  while  progres- 
sive muscular  atrophy  attacks  muscles  only  anatomically  related. 
There  are  cases,  however,  which  seem  to  be  on  the  border  line 
between  the  two  diseases. 

Syringo-myelia  is  distinguished  by  the  presence  of  peculiar 
sensory  and  trophic  disorders. 

Neuritis  caused  by  lead-poisoning  is  detected  by  the  history  of 
the  case,  its  tendency  to  affect  the  extensors  of  the  arm  chiefly,and 
the  absence  of  a  progressive  tendency.  Sometimes,  however,  lead- 
poisoning  and  palsy  end  in  true  prt)gressive  muscular  atrophy. 

Ordinary  multiple  neuritis  is  distinguished  easily  by  its  rapid 
onset  and  the  presence  of  painful  symptoms. 

The  hereditary  or  "  leg  type  "  of  progressive  muscular  atrophy 
is  characterized  by  its  beginning  in  the  legs,  by  a  good  deal  of 
sensory  disturbance,  typical  degeneration  reactions,  and  heredi 
tary  or  family  history. 


268  DISEASES   OF  THE  NERVOUS   SYSTEM. 

Treatment.— The  patient  should  be  well  fed  and  have  rest, 
quiet,  and  fresh  air.  Careful  local  faradization  and  galvanization 
of  the  spine  and  neck  are  indicated.  Massage  does  no  good. 
Hypodermic  injections  of  strychnine  in  the  affected  member, 
gr-  iu  to  ^  daily,  the  internal  use  of  arsenic,  phosphorus,  iron, 
quinine,  and  cod-liver  oil  sometimes  are  beneficial. 

In  a  few  cases  with  a  syphilitic  history,  mercury  and  iodide  of 
potash  have  proved  useful.  The  essentials  of  treatment  are  rest, 
electricity,  strychnine  locally,  the  administration  of  powerful 
tonics,  and  over-feeding.  Ts^itroglycerin,  morphine,  atropine,  ni- 
trate of  silver,  chloride  of  gold  and  of  barium,  and  the  nitrate  of 
uranium  may  be  tried. 

Progressive  Hereditary  Muscular  Atrophy  of  Leg 
Type  (Charcot-Marie  Type). 

This  is  a  hereditary  or  family  muscular  atrophy  of  central  (or 
neuritic?)  origin,  beginning  in  the  legs  and  extending  uj^ward. 
It  affects  males  more  than  females,  but  the  difference  is  not 
great.  It  almost  always  begins  before  the  age  of  twenty.  It 
attacks  first  the  muscles  of  the  leg,  not  the  foot,  involving  the 
peronei,  then  the  extensors  of  the  toes,  then  the  calf  muscles. 
The  thighs  escape  till  later.  After  some  years  the  upper  extrem- 
ities and  small  hand  muscles  are  reached.  The  shoulder  and 
arm,  neck  and  trunk  muscles  escape.  There  are  occasionally 
fibrillary  contractions ;  and  always  partial  or  complete  degener- 
ative electrical  reactions.  The  patients  comjDlain  of  some  pain 
and  numbness,  but  there  is  no  anaesthesia. 

The  disease  runs  a  long  course,  with  remissions,  and  resem- 
bles in  prognosis  the  dystrophies.  The  outlook  is  better  than  in 
the  arm  type,  but  the  disease  is  not  curable. 

Some  authorities  assert  that  the  disease  is  due  to  a  progressive 
degenerative  neuritis.  In  the  writer's  ojoinion  the  anterior  horns 
of  the  spinal  cord  are  primarily  attacked.* 

The  treatment  is  the  same  as  for  the  other  forms  of  hereditary 
muscular  atrophy. 

Amyotrophic  Lateral  Sclerosis. 

This  is  a  form  of  progressive  muscular  atrophy  associated  with 
spastic  symptoms  and  paralysis.  It  ends  in  or  may  be  early  as- 
sociated with  bulbar  paralysis  or  even  with  ophthalmoplegia. 

The  etiology  resembles  that  of  oixlinary  forms  of  spinal  mus- 
cular atrophy. 

*  The  writer  has  seen  the  disease  in  a  typical  form  in  one  member  of  the  first 
generation,  in  two  members  of  the  second.  A  child  of  one  of  the  latter  had,  at  the 
age  of  two  years,  a  typical  attack  of  anterior  poliomyelitis. 


MUSCULAR   ATROPHIES   AND   DYSTROPHIES.  269 

The  symptoms  of  typical  eases  such  as  were  first  described  by 
Charcot  are  those  of  a  slowly  developing  paralysis.  This  affects 
the  upper  extremities  first  and  spreads  diffusely.  The  atrophy  is 
less  marked  than  the  paralysis.  There  is  rigidity,  exaggerated 
reflexes,  and  sometimes  tremor.  Fibrillary  contractions  are  pres- 
ent. There  are  no  notable  sensory  symptoms.  The  legs  are 
affected  later;  the  paralysis  and  spastic  condition  of  the  legs 
are  antecedent  to  the  atrophy.  The  visceral  centres  are  not  in- 
volved. The  disease  progresses  rather  rapidly  and  finally  in- 
volves the  medulla,  causing  bulbar  paralysis  and  death.  Some- 
times ophthalmoplegia  is  also  present. 

In  less  typical  cases  the  disease  begins  with  spinal  and  bulbar 
symptoms  almost  simultaneously.  In  a  case  under  the  writer's 
observation  there  was  ophthalmoplegia,  bulbar  paralysis,  and 
spinal  atrophy  beginning  at  nearly  the  same  time.  Ordinary 
cases  of  spinal  muscular  atrophy  may  also  be  early  associated 
with  rigidity  and  exaggerated  reflexes.  The  jaw  jerk  is  often 
increased  in  this  disease,  which  cannot  be  said  to  be  really  dis- 
tinct from  progressive  spinal  muscular  atrophy ;  it  runs  usually  a 
rapid  course,  causing  death  in  two  or  three  years. 

THE   PROGRESSIVE   MUSCULAR  DYSTROPHIES. 

This  name  is  given  to  various  forms  of  progressive  muscular 
atrophy  in  which  the  disease  is  hereditary  in  character  and  at- 
tacks primarily  the  muscles.  Although  a  muscular  disease,  yet 
its  close  relationship  with  spinal  muscular  atroi^hies  leads  us  to 
describe  it  here. 

A  number  of  types  have  been  described,  the  distinctions  being 
based  chiefly  on  the  part  of  the  body  first  affected.  These  types 
are  not  of  great  importance,  but  may  be  enumerated  here  for 
convenience : 

1.  Pseudo-muscular  hypertrophy. 

{a)  Leyden-Mobius  or  hereditary  type,  appearing  in  children, 
beginning  in  back  and  lower  limbs. 

2.  Erb's  juvenile  type,  or  scapulo-humeral  type,  beginning  in 
childhood  or  youth,  usually  in  the  shoulder  girdle  or  trunk. 

3.  Landouzy-Dejerine  type,  or  infantile  progressive  muscular 
atrophy  of  D  uchehne,  or  f acio-scapulo-humeral  type.  It  resembles 
the  preceding  form,  with  the  exception  that  it  involves  the  face. 

4.  The  peroneal  or  leg  type  has  been  classed  with  the  dys- 
trophies, but  is  probably  of  spinal  or  neuritic  origin,  and  has  been 
described  with  the  atrophies  (see  page  268). 

The  essential  unity  of  all  these  different  forms  is  shown  by  the 
fact  that  cases  occur  in  which  pseudo-hypertrophy  takes  place 
in  the  scapulo-humeral  and  other  types,  by  the  fact  that  a  dis- 


270 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


ease  resembliug  pseudo-hypertrophic  paralysis  occurs  without 
any  hypertrophy,  and  by  the  fact  that  different  types  occur  in 
the  same  family.  The  unity  of  the  spinal  and  muscular  forms  is 
shown  bv  the  same  kind  of  clinical  evidence. 


A.  B. 

Fig.  118. — Showing  the  Parts  First  Attacked  in  the  Different  Types  op 
Muscular  Dystrophy  and  Muscular  Atrophy.  The  shaded  parts  iu  A  show  the 
place  of  onset  of  progressive  muscular  atrophy-  of  ordinary  or  Duchenue-Araa  type, 
of  leg  type,  and  of  tj'pes  2  and  3  in  text.  B  shows  place  of  onset  of  types  1  and  (a) 
in  text. 

At  the  same  time  the  classical  types  of  dystrophies  are  very 
different  clinically  from  the  spinal  amyotrophies  and  hence  must 
be  separately  described.  The  differences  will  be  shown  under 
the  head  of  diagnosis. 

Pseudo-Muscular  Hypertrophy  (Atrophia  Musculorum 

LlPOMATO^US). 

This,  is  a  disease  beginning  in  childhood  and  characterized  by 
a  progressive  weakness  of  the  legs  associated  with  an  apparent 
muscular  hypertrophy  due  to  a  deposit  of  fat  in  the  wasting 
muscles. 


MUSCULAR   ATROPHIES   AND   DYSTROPHIES. 


271 


Etiology.— The  disease  attacks  boys  much  oftener  than  girls. 
It  begins,  in  the  vast  majority  of  cases,  under  the  age  of  ten, 
often  at  the  close  of  infancy,  very  rarely  not  till  after  puberty. 
Heredity  is  a  very  important  factor  (in  three-fifths  of  eases),  the 
hereditary  influence  being  almost  always  transmitted  by  the 
mother.  A  psychopathic  or  neuropathic  condition  is  often  found 
in  the  ancestry.  jS^euroses,  syph- 
ilis, intemi^erance,  consanguin- 
ity, are  not  factors  in  hereditary 
causation.  Injury  and  an  acute 
disease  sometimes  appear  to  act 
as  exciting  causes. 

JSj/m2Jto?ns. —  The  first  symp- 
tom noticed  is  a  weakness  in  the  legs,  /  ^ 
which  shows  itself  in  a  peculiar  "  wad-  i  ^ 
dling  gait"  and  a  tendency  to  stumble  ]~ 
and  fall.  A  little  later  (fifth  or  sixth  W 
year)  an  ajjparent  hypertrophy  of  leg 
muscles,  particularly  of  those  of  the 
calves,  develops.  The  extensors  of  the 
knee  or  one  of  them  and  the  gluteal 
and  lumbar  muscles  may  also  be  af- 
fected. Sometimes  the  hypertrophy  is 
very  great,  at  other  times  it  is  barely 
noticeable  (Fig.  119).  The  affected  part 
has  a  peculiar,  hard,  non-elastic  feeling 
to  the  hand,  not  like  that  of  normal  mus- 
cle. In  the  upper  part  of  the  body  the 
hypertrophy  oftenest  attacks  the  infra- 
spinatus. The  supra-spinatus  and  del- 
toid may  be  somewhat  involved.  The 
lower  parts  of  the  pectoralis  major  and  latissimus  dorsi  are  also 
usually  atrophied,  giving  a  characteristic  appearance  to  the 
shoulders.  The  upper-arm  muscles  are  often  slightly  wasted, 
the  forearm,  neck,  and  face  rarely.  The  tongue  may  be  hyper- 
trophied. 

Along  with  the  pseudo-hypertrophy  there  occurs  an  atrophy 
of  certain  groups  of  muscles ;  and  after  a  time  the  pseudo-hyper- 
trophy disappears  and  an  atrophy  takes  its  place.  In  the  lower 
limbs  the  muscles  most  atrophied  are  the  fiexors  of  the  hips,  then 
the  extensors  of  the  knee  and  those  of  the  hip.  The  calf  muscles 
fail  before  the  anterior  tibial.  The  atrophy  and  consequent 
weakness  of  the  lower-limb  muscles  causes  great  difficulty  in 
going  upstairs,  the  gait  becomes  more  waddling,  and  the  pa- 
tient loses  the  power  of  getting  up  when  lying  on  the  floor. 
These  peculiarities  are  due  chiefly  to  the  weakness  in  the  exten- 


FiG.  119.— Pseudo-Muscular 
Hypertrophy  (Erb). 


272  DISEASES   OF  THE   NERVOUS   SYSTEM. 

sors  of  the  knees,  the  extensors  of  the  hip,  and  the  flexors  of 
the  hip.  By  reason  of  the  same  defects,  the  child  wlien  standing 
has  an  antero-posterior  curvature  of  the  spine  with  the  concavity 
backward  (lordosis).  This  is  due  to  the  weakness  of  the  exten- 
sors of  the  hips,  which,  acting  from  the  hips,  are  unable  to  tilt  the 
pelvis  back.  On  sitting  this  lordosis  disappears,  and  is  replaced 
often  by  a  curve  in  the  oj)posite  direction  due  to  weakness  of  the 
erectors  of  the  spine.  There  may  be  some  lateral  curvature  also. 
In  consequence  of  the  weakness  and  contractures  of  the  leg  mus- 
cles, there  early  develops  a  talipes  equinus,  and  later  the  legs  may 
become  flexed  on  the  hips  and  the  forearms  on  the  arms. 

The  muscles  show  no  fibrillary  twitchings  and  rarely  any  de- 
generative reactions,  but  there  is  sometimes  a  peculiar  tetanic 
contraction  with  both  the  faradic  and  the  galvanic  current. 

The  knee  jerks  and  elbow  jerks  gradually  weaken  and  in  time 
are  lost. 

There  is  no  pain  or  other  disturbance  of  sensibility. 

The  affected  parts  feel  cold  and  look  reddened  as  if  from  defi- 
cient vasomotor  innervation.  The  organic  spinal  centres  are  not 
involved.     Intelligence  is  usally  good. 

Course. — The  disease  runs  a  chronic  but  variable  course.  Its 
progress  is  at  first  slow ;  after  walking  becomesi  impossible  it  may 
progress.  It  lasts  from  ten  to  twenty-five  years.  In  a  few  cases 
patients  have  reached  the  age  of  fifty  or  sixty  years,  even  when 
the  disease  began  in  youth.  The  earlier  the  disease  begins  the 
more  rapidly  it  extends ;  the  more  pronounced  the  tendency  to 
lipomatosis,  the  more  rapid  is  the  course. 

Pathological  Anato7ny.— This  diseeise,  like  the  other  forms  of 
dystrophy,  is  a  degenerative  one,  the  process  affecting  first  the 
muscle  fibres;  the  connective  tissue  and  terminal  nerve  filaments 
being  secondarily  involved.  In  the  same  iDatient  and  even  the 
same  muscle  the  most  varied  changes  may  be  noted.  In  the 
early  stages  there  is  a  true  hypertrophy  of  some  of  the  fibres,  a 
condition  thought  to  be  characteristic  of  the  muscular  dystro- 
phies in  distinction  from  the  spinal  atrophies.  Besides  swelling 
and  hypertrophy  of  fibres,  one  sees  atrophy  of  the  fibres;  the 
bundles  are  rounded;  there  is  increase  of  muscle  nuclei,  splitting 
of  fibres,  vacuolization,  and  tendency  to  break  up  into  fibrillse 
(Erb).  The  connective  tissue  at  first  show^s  evidence  of  irrita- 
tion and  proliferation.  Finally,  as  the  muscular  atrophy  pro- 
gresses, connective  tissue  increases  and  takes  its  place,  until  a 
dense,  hard  myo-sclerosis  results.  In  some  parts  there  is  deposit 
of  fat  in  the  connective-tissue  cells,  and  this  may  increase  until 
an  extensive  lipomatosis  exists.  In  the  later  stage  of  the  disease 
the  fat  deposits  are  absorbed  and  there  is  only  atrophied  mus- 
cle and  connective  tissue.     The  nerves  and  spinal  cord  are  usu- 


MUSCULAR   ATROPHIES   AND   DYSTROPHIES. 


27: 


ally  normal ;  when  changes  are  found  they  are  secondary  to  the 
muscular  disease  (Fig.  120). 

The  process  is  then,  first,  hypertrophy  of  muscle  fibre  and  in- 
crease of  muscle  nuclei,  swelling  and  rounding  of  fibres,  and  spill- 
ing of  the  same;  then  increase  of  connective  tissue,  with  corre- 
sponding atrophy  of  muscle  and  deposit  of  fat. 

The  process  is  a  primary  degeneration  due  to  an  inherent 
nutritional  weakness  of  the  muscle.     In  a  measure  it  is  true  that 


'K 


Fig.  120.  — Partially  Diagrammatic,  showing  A,  hypertrophied  fibres;  B, 
mixture  of  hypertrophy  and  atrophy  ;  C,  D,  atrophy  and  fatty  deposit ;  v,  vacuoli- 
zation ;  s,  sphtting  ;  h,  hypertrophy  of  fibres  ;  g,  thickened  blood-vessel  (Erb). 


those  muscles  embryologically  latest  developed  are  earliest  at- 
tacked. 

2.  The  juvenile  form  of  Erb  or  scapulo-humeral  form  of  dys- 
trophy begins  in  childhood  or  early  youth,  a  little  later  than 
pseudo-hypertrophy.  The  shoulder  girdle  is  first  affected,  later 
the  arm.  The  forearm  and  legs  are  attacked  very  late.  Part  of 
the  pectorals,  part  of  the  trapezii,  latissimus  dorsi,  rhomboid, 
upper-arm  muscles  and  supinators  are  affected,  while  the  supra 
and  infra  spinati  and  forearm  and  hand  usually  escape.  There 
may  be  true  and  false  muscular  hypertrophy.  There  are  no  fib- 
rillary contractions  or  degenerative  reactions. 
j8 


274 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


3.  The  facio-scaimlo-humeral  form  or  infantile  progressive 
muscular  atrophy  begins  in  early  childhood  (third  or  fourth  j^ear) 
usually,  but  may  develop  late.  The  atrophy  attacks  first  the 
face,  giving  a  characteristic  appearance  known  as  the  myopathic 
facies.  There  is  a  weakness  of  the  oral  muscle,  which  causes 
the  lips  to  protrude  and  produces  a  symptom  called  the  "tapir- 
mouth."  The  atrophy  respects  the 
eye  muscles  as  well  as  those  of  mas- 
tication and  deglutition.  It  extends 
to  the  shoulders  and  arms  next,  then 
it  pursues  the  ordinary  course  of  the 
dystrophies. 


Fig.  v:-2. 
Fig.  121.— Mcscular   Dystrophy  uaving  Characters   of   Juvenile  Type   (2) 

AND  PsEUDO-HyPERTROPHIC  TyPE   (la)    (PUTZEI.). 

Fig.  122.— Juvenile  Type,  showing  atrophy  in  shoulder  and  arms  (Erb). 


Prognosis. — The  patient  never  recovers,  but  the  disease  some- 
times comes  to  a  standstill  and  there  may  even  be  some  improve- 
ment, especially  in  cases  beginning  late. 

Treatment.— T\ie  prophylaxis  is  important.  It  consists  in  pre- 
venting the  marriage  of  women  belonging  to  dystrophic  families; 
if  a  dystrophy  has  developed  in  one  child,  it  would  be  unwise 
to  take  the  risk  of  bringing  others  into  the  world.  Or  if  children 
are  already  born,  they  should  receive  the  most  careful  nourish- 


MUSCULAR   ATROPHIES   AND   DYSTROPHIES. 


275 


nient,  out-door  life  should  be  secured,  and  the  dangers  from 
trauma  and  the  infective  diseases  be  prevented.  Infants  should 
not  be  suckled  by  the  mother  if  she  belongs  to  the  dystrophic 
family. 

The  moderate  use  of  massage  and  gymnastics  is  very  impor- 
tant and  useful.  All  kinds  of  tonic  measures  are  indicated,  such 
as  cold  baths,  good  nourishment,  arsenic,  strychnine,  and  phos- 
phorus and  fats.  Tenotomy  and  other  orthopedic  measures  may 
be  useful  in  the  later  stages. 


Fig.  123.— Showing  Changes  in  Arthritic  Muscular  Atrophy.  1,  Normal 
fibre  ;  2,  atrophied  fibre  ;  3,  vacuolated  fibre  ;  4,  connective-tissue  proliferation 
( Darkschewitch). 


Arthritic  Muscular  Atrophy. 

In  inflammation  of  joints  the  muscles  moving  are  affected  by 
a  simple  atrophy  which  is  called  arthritic. 

^^/oZo^^.— Rheumatic  arthritis  is  the  commonest  cause. 

Symptoms.— The  shoulder-girdle  muscles  are  oftenest  affected. 
Whatever  the  joint,  it  is  the  extensor  muscles  which  are  first  and 
most  attacked ;  the  muscles  above  the  joint  are  more  susceptible 
to  the  atrophy  than  those  below.  The  atrophy  is  rather  rapid 
in  the  first  few  weeks  and  then  becomes  slower.     The  muscles 


276  DISEASES   OF   THE   NERVOUS   SYSTEM. 

affected  waste  throughout  their  whole  length.  They  show  no 
fibrillary  contraction  and  no  degenerative  electrical  reaction. 
There  is  often  an  increased  irritability,  so  that  an  exaggerated 
tendon  reflex  or  even  clonus  may  be  produced.  There  is  no  pain 
or  tenderness  or  anaesthesia  in  the  muscles. 

Fatholog I/.— The  anatomical  change  is  a  simple  atrophy  and 
shrinking  of  the  muscle  fibres,  with  some  increase  in  muscle 
nuclei,  little  vacuolation,  no  swelling  or  splitting  of  fibres  (Dark- 
schewitch— Fig.  123).  There  is  some  increase  in  interstitial  tis~ 
sue,  but  this  is  slight.     The  nerves  and  spinal  cord  are  normal. 

The  atrophy  is  probably  due  to  reflex  action.  It  is  a  reflex 
tropho-neurosis.     Even  a  neuralgic  joint  may  cause  an  atrophy. 

The  prognosis  is  good.  If  the  arthritis  gets  well  the  muscles 
are  also  restored. 

The  treatment  consists  of  electricity  and  gentle  massage  and 
exercise.     Internal  treatment  must  be  directed  to  the  arthritis. 

Occupation  Muscular  Atrophies. 

As  a  result  of  constant  over-use  muscles  sometimes  atrophy. 
This  applies  especially  to  the  smaller  muscles  of  the  hand.  Thus 
there  occurs  an  atrophy  of  the  thenar  eminence  in  lapidaries 
and  in  persons  who  constantly  use  this  group  of  small  muscles. 

The  biceps  sometimes  wastes  in  smiths,  and  I  have  seen  atro' 
phy  of  the  calf  muscles  in  a  ballet-dancer. 

The  disease  does  not  tend  to  extend  beyond  the  muscular 
group  first  attacked.  Its  seat  is  probably  the  muscles  themselves. 
The  treatment  is  rest. 


CHAPTER  XY. 

TUMORS  AND   CAVITIES   OF  THE   SPINAL  CORD. 


Miology.— Tumors  occur  rarely  in  the  spinal  cord.  The  largest 
tables  of  cases  include  less  than  one  hundred.  The  commonest 
age  is  thirty  to  fifty ;  tubercle  occurs  earlier  (fifteen  to  thirty-five 
— Herter)  and  lipoma  is  con- 
genital. Males  are  more  sub- 
ject than  females.  Tuber- 
culosis, syphilis,  and  cancer 
predispose  to  the  disease. 
Injuries  and  exposures  ap- 
pear sometimes  to  excite  the 
growth  of  spinal  neoplasms. 

Symptoms.  —  These  vary 
with  the  location,  character, 
size,  and  rate  of  the  growth 
of  the  tumor.  No  definite 
clinical  picture  can  be  drawn. 
The  symptoms  are  such  as  re- 
sult from  a  foreign  body  slow- 
ly and  iDrogressively  irritating 
and  destroying  the  roots  and 
substance  of  the  spinal  cord. 
Pain  appears  early  and  is 
very  constant,  continuous, 
and  severe.  It  is  generally  re- 
ferred to  nerves  running  out 
from  the  cord  in  the  region 
of  the  tumor;  a  girdle  sensa- 
tion is  felt.  Numbness,  hy- 
persesthesia,  and  later  anaes- 
thesia occur.  Tenderness  over 
the  spine  and  rigidity  are  not 
very  frequent.  The  sensory 
symptoms  are  usually  more 
on  one  side,  but  may  become 
bilateral.  Spasm,  contracture, 
and  exaggerated  reflexes  usu- 
ally soon  develop,    involving 


R 

Fig.  124.— Showing  the  Condition  in  a 
Brown-Sequard  Paralysis  due  to  a  Tumor 
Growing  in  the  Left  Side  op  the  Spinal 
Cord.  On  the  left  side,  hyperaesthesia, 
ataxia,  paralysis,  exaggerated  reflexes.  At 
the  upper  limit  is  a  band  of  anaesthesia.  On 
right  side,  anaesthesia. 


278 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


one  or  both  legs  or  an  arm  and  leg.  Later  paralysis,  atrophy, 
loss  of  control  of  the  bladder  and  rectum,  and  bed-sores  follow, 
and  death  ensues  from  exhaustion. 

"When  the  disease  is  cervical  the  four  extremities  and  trunk 
muscles  may  be  gradually  involved,  and  there  is  rigidity  of  the 
neck  and  optic  neuritis.  If  lower  down,  there  develops  a  hemi- 
paraplegia,  later  a  complete  parajDlegia,  usually  with  exaggerated 
reflexes.  If  the  tumor  is  in  the  lumbar  region  the  reflexes  are 
sooner  lost  and  the  sphincters  early  involved. 

A  rather  frequent  type  of  symptoms  caused  by  spinal  tumors 
is  that  known  as  a  Broicn-Sequard paralysis  or  hemiparaplegia. 
In  a  typical  case  of  this  kind  there  is  paralysis  of  motion  and 
muscle  sense  on  the  side  of  the  lesion,  paralysis  of  cutaneous  sen- 
sation, especially  of  pain,  and  temperature  on  the  opposite  side. 
On  the  side  of  the  lesion  the  temperature  may  be  slightly  raised ; 


Fig.  125.— Showing  the  Mechanism  op  the  Production  of  a  Brown-Seqcari> 
Paralysis.  The  shaded  part  on  the  left  represents  the  lesion.  This  involves  the 
pyramidal  tract  and  motor  fibres  M,  causing  paralysis  and  spasm  on  same  side;  also 
the  muscle  sense  nerves  M  S  on  same  side  and  the  cutaneous  sensory  nerves  C  S 
of  opposite  side. 


there  is  often  hypersesthesia,  and  reflex  action  is  increased. 
There  may  be  a  band  of  anaesthesia  at  the  level  of  the  lesion  and 
on  the  same  side  (Figs.  124,  125). 

The  symptoms  vary  according  as  the  tumor  is  outside  or  in- 
side the  dura.  The  common  extra -dural  forms  are  lipoma,  cancer, 
gumma,  and  sarcoma.  The  greater  amount  of  motor  and  sensory 
irritation,  the  evidence  of  some  vertebral  disease,  existence  of 
malignant  tumor  elsewhere,  the  absence  usually  of  hemij^ara- 
plegia,  characterize  extra-medullary  tumors.  The  common 
forms  of  intra-dural  or  medullary  tumor  are  glioma  and  tubercle. 
In  these  cases  pain  and  spasm  and  rigidity  are  rather  less  com- 
mon in  the  early  stage;  hemi-paraplegia  is  more  common.  A 
secondary  myelitis  sometimes  develops. 

The  duration  of  the  disease  ranges  from  three  months  to  five 
years,  the  average  being  two  or  three  years. 

Pathology  and  Pathological  Anatomy.— A\\  forms  of  tumor 
occur,  but  the  commonest  are  gliomata  and  sarcomata,  and  after 


TUMORS   AND   CAVITIES   OF   THE   SPINAL  CORD.        279 


this  fibromata,  myxomata,  gummata,  and  tubercles.  Cancer  is 
rare ;  ecliinococcus  and  cysticercus  are  the  only  parasitic  tumors 
found.  The  majority  start  from  the  membranes,  next  from  the 
cord,  and  fewest  from  the  vertebrae. 

The  meningeal  tumors  are  mostly  sarcomata  and  their  various 
modifications,  fibroma,  enchon- 
droma,  carcinoma,  and  lipoma. 
The  myelonic  or  intra-spinal 
tumors  are  commonly  glio- 
mata,  sarcomata,  tubercle,  and 
syphilomata. 

Spinal  tumors  are  small  in 
size,  ranging  from  one-fifth  to 
one  and  one-fifth  inches  (one- 
half  to  three  centimetres)  in 
diameter.  The  glioma  may 
diffuse  itself  for  a  long  dis- 
tance through  the  centre  of 
the  cord,  forming  cavities  (syr- 
ingo-myelia).  The  sarcomata 
may  likewise  be  irregularly 
spread  along  the  surface  of  the 
cord.  Spinal  tumors  are  usu- 
ally single,  but  fibromata,  the 
parasites,  and  sarcomata  may 
be  multiple. 

The  favorite  locations  for 
spinal  tumors  are  just  below 
the  mid-cervical,  the  upper  and 
the  low^er  dorsal  regions.  The 
secondary  changes  produced 
by  tumors  are  softening,  hem- 
orrhages, secondary  degenera- 
tions, and  inflammatory  reac- 
tion. The  origin  and  histology 
of  spinal  tumors  does  not  differ 
from  that  of  tumors  elsewhere. 

The  Diagnosis.— Th.Q  disease 
has  to  be  distinguished  from 
vertebral  caries,  transverse  myelitis,  and  hypertrophic  pachymen- 
ingitis. The  points  to  be  noted  as  regards  caries  are  the  absence 
of  an  external  tumor  or  kyphosis;  the  small  degree  of  tenderness 
and  rigidity,  the  age,  and  absence  of  tubercular  diathesis.  The 
progressive  course,  beginning  with  pain,  followed  by  motor  and 
then  sensory  paralysis,  and  the  localization  of  the  symptoms  ex- 
cludes myelitis.  The  differentiation  from  hypertrophic  pachy- 
meningitis is  often  very  difficult. 


Fig.  126.— Sarcoma  of  Spinal  Cord, 
Mid-cervical  Region. 


280  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  character  of  the  tumor  cannot  often  be  determined  cer- 
tainly, Tlie  probabihties  are  in  favor  of  sarcoma  or  ghoma,  es- 
pecially in  middle  life.  Syphiloma  may  be  suspected  from  the 
history  and  results  of  treatment.     Tubercle  is  very  rare. 

The  2^rognosis  is  bad  except  in  syphiloma,  and  even  here  it 
may  be  serious.  Tubercle  may  perhaps  cease  to  grow.  Surgical 
interference  now  saves  the  life  of  some  cases. 

Treatment. — In  syphilitic  tumors  appropriate  remedies  may 
do  good  and  should  be  vigorously  used.  In  tubercle,  tonic 
treatment,  iodine,  and  cod-liver  oil  may  be  of  service.  In  gliomata 
and  sarcomata,  nitrate  of  silver  and  arsenic  may  be  tried.  In 
other  forms,  symptomatic  treatment  is  all  that  can  be  recom- 
mended medically.  In  all  cases  of  spinal  tumor  surgical  inter- 
ference should  be  considered ;  extra-dural  tumors,  if  taken  early, 
can  be  removed  with  great  benefit.  Even  in  medullary  tumors 
enucleation  may  do  some  good  in  the  early  stage.  Exploratory 
operations  are  justifiable  if  there  is  no  question  as  to  the  diagno- 
sis of  tumor.  The  mortality  from  such  operation  in  capable 
hands  is  very  low,  though  it  is  more  dangerous  than  trephining 
the  skull. 


CAVITIES   IN    THE   SPINAL   CORD. 

The  cavities  of  the  spinal  cord  are  known  as 

1.  Hydromyelia. 

2.  Myelitic  cavities. 

3.  Syringo-myelia. 

There  may  be  various  combinations  of  these  processes,  the 
most  common  being  a  combination  of  hydromyelia  and  syringo- 
myeUa. 

Hydromyelia. 

This  is  a  dilatation  of  the  central  canal  of  the  cord,  the  cavity 
being  filled  with  fluid.  The  condition  may  be  associated  with 
hydrocephalus  or  with  spina  bifida,  or  it  may  be  independent  of 
these  conditions.  The  dilatation  may  be  cystic  and  irregular  or, 
as  is  more  usual,  extend  throughout  the  cord.  The  dilatation 
extends  more  posteriorly,  because  the  posterior  columns  are 
formed  latest.  The  abnormality  may  be  slight  and  give  rise  to  no 
symptoms.  Or  a  pathological  process  like  a  gliomatosis  may  de- 
velop upon  it. 

Myelitic  axd  Hemorrpagic  Cavities. 

Such  cavities  may  be  formed  in  the  cord  by  a  central  excavat- 
ing myelitis  or  by  small  hemorrhages.  These  cavities  are  usually 
small,  irregularly  distributed,  and  are  lined  with  connective  tis- 
sue. They  may  be  formed  in  rare  cases  in  connection  with  hy- 
dromj'elia  or  neoplasms. 


TUMORS    AND   CAVITIES   OF  THE   SPINAL   CORD.        281 


Syringo-Myelia. 

Syringo-myelia  is  a  disease  of  the  spinal  cord  characterized  by 
a  development  of  gliomatous  tissue  in  the  central  parts,  with  for- 
mation of  cavities.  Clinically  the  disease  is  sometimes  charac- 
terized by  peculiar  disturbances  of  sensation  and  nutrition.  In 
many  cases,  however,  the  symptoms  are  atypical  and  the  dis- 
ease cannot  be  recog^nized  during  life. 

The  description  here  yiven  corresponds  to  the  classic  mani- 
festation of  the  disease,  and  it  is  intended  to  refer  to  syringo- 
myelia produced  by  gliomatosis  only. 

Etiology. — The  disease  is  rare,  about  two  hundred  cases  hav- 
ing been  reported.     It  is  more  frequent  than  amyotrophic  lateral 


1.  '  2. 

Fig.  127.— Distribution  of  Cutaneous  Anesthesia  in  Syringo-Myelia.  1 
shows  area  of  analgesia  :  2  shows  that  of  thermo-ana?sthesia.  The  darker  shades 
show  where  there  is  anaesthesia  to  pain  and  temperatui*e  (Bruhl). 

sclerosis  and  rather  less  frequent  than  multiple  sclerosis.  It  oc- 
curs oftener  in  men  than  women,  and  develops  early  in  life,  be- 
tween the  ages  of  fifteen  and  twenty-five. 

It  occurs  especially  in  persons  who  follow  manual  occupations 
such  as  butchers,  tailors,  etc.  Traumatism,  pregnancy,  and  in- 
fectious diseases  seem  occasionally  to  give  rise  to  it.  Heredity, 
syphilis,  and  alcohol  are  not  causal  factors. 

Symptoms.— The  disease  begins  insidiously  with  some  achmg 
pains  in  the  neck  and  arms  and  parassthesia  of  the  hands.  There 
is  soon  a  muscular  atrophy  of  the  hands  resembling  spinal  pro- 
gressive muscular  atrophy,  with  perhaps  anaesthesia.  As  the  dis- 
ease progresses  the  weakness  and  atrophy  of  the  hand  muscles 
become  more  noticeable  and  gradually  extend  toward  the  trunk. 
The  atrophv  comes  on  in  both  extremities  at  about  the  same  time. 


283 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


Fibrillary  contractions  and  partial  degeneration  reaction  may  be 
observed.  Cutaneous  anaesthesia  of  the  affected  hand  and  arm 
to  temperature  and  pain,  but  not  to  touch,  takes  place ;  and  this 
_  is  so  marked  as  to  be  al- 

most pathognomonic  of  the 
disease  (Fig.  127). 

The  legs  do  not  become 
affected  until  late,  and  then 
generally  show  a  spastic 
paraplegia.  The  throat 
and  face  are  rarely  in- 
volved. There  is  a  scolio- 
sis of  the  sjoine.  generally 
in  the  dorso-lumbar  region 
(Fig.  128). 

Vasomotor,  secretory, 
and  trophic  symptoms  are 
prominent.  The  hands 
may  be  oedematous  or  red 
and  congested.  Sweating 
or  dryness  of  the  skin  may 
occur.  Eruptions  appear 
on  the  skin,  such  as  bullae, 
herpes,  and  eczema.  Pain- 
less whitlows  attack  the 
fingers  and  may  destroy 
the  terminal  phalanges. 
Erosions  and  ulcerations 
also  occur.  The  nails  be- 
come dry,  brittle,  and  drop 
off  (Fig.  129).  Arthropa- 
thies and  spontaneous  frac- 
tures have  been  observed. 
The  pupils  may  be  un- 
equal and  the  "  bulb  re- 
tracted. 

Late  in  the  disease 
symptoms  of  involvement 
of  the  medulla  develop.  At 
this  time  also  the  bladder, 
rectum,  and  genital  centres 
are  attacked.  The  disease 
progresses  slowh'  for  years, 
with  remissions  of  various 
degree. 

The  cardinal  symptoms 
are  a  progressive  muscu- 
lar atrophy,  with  a  pecu- 
liar partial  anaesthesia, 
trophic  disturbances,  and 
scoliosis. 

Pathological  Anatomy. — The  seat  of  the  disease  is  the  sub- 
stance of  the  cord.  On  opening  it  by  transverse  sections  one 
finds  one  or  more  cavities  extending  in  various  degrees  up  and 
down.  The  most  frequent  primary  site  is  the  cervical  swelHng. 
From  here  it  usually  passes  down  and  may  reach  the  wliole 
length   of  the  cord.     It  also  extends  upward  and  may  involve 


Fig.  128.— Showing  Curvature  op  Spine  in 
Syringo-Myelia  (Erb;. 


TUMORS   AND   CAVITIES   OF   THE   SPINAL  CORD.        283 

the  medulla  and  the  nuclei  of  the  cranial  nerves.  The  cavities 
are  of  irregular  shape,  small  size,  and  filled  with  a  liquid  like 
the  cerebro-spinal  fluid.  They  are  situated  oftenest  posterior 
to  the  commissure  and  involve  one  or  both  posterior  horns,  but 
they  may  be  so  extensive  as  to  involve  almost  the  whole  of  the 
centre  of  the  cord  at  some  levels.  The  walls  are  usually  lined  by  a 
membrane  and  surrounded  by  a  gliomatous  tissue  (Figs.  130-135). 
This  membrane  is  composed  of  a  rather  dense  gliomatous  tis- 
sue. It  may  be  absent  in  some  parts.  The  glla  cells  are  in  vari- 
ous stages  of  development  and  degeneration.  In  parts  of  the 
cord  the  new  growth  may  form  a  large  and  solid  mass  occupying 


Fig.    129.— Showing    Hand    in    Syringo-Myelia    op   Type   of    Morvan's   Dis- 
ease (Erb). 

most  of  the  centl-e  of  the  cord.  Small  hemorrhages  and  foci  of 
myelitis  may  be  present.  In  some  cases  there  is  evidence  of  a 
dilated  central  canal,  with  neuroglia  hyperplasia  of  the  walls  and 
a  gliomatous  infiltration  about  this.  The  epithelium  of  the  cen- 
tral canal  mav  form  part  of  the  wall  of  the  cavity. 

Pathology^— At  about  the  sixth  week  of  foetal  life  the  central 
canal  of  the  cord  is  large,  diamond-shaped,  and  reaches  nearly  to 
the  anterior  and  posterior  surfaces  of  the  cord.  This  cavity  grad- 
ually contracts  and  unites  in  the  middle,  the  anterior  part  forming 
the  central  canal  and  the  posterior  part  the  posterior  septum. 
The  posterior  part  may,  through  some  embryological  defect,  fail 
to  close,  and  a  congenital  cavity  may  be  left.  About  this  a  gli- 
oma may  develop,  and  we  have  syringo-myelia.     The  central  canal 


284 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


may  remain  imperfectly  contracted,  and  a  syring:o-myelia  may 
develop  in  connection  with  it.  Probably  most  cases  ot  syringo- 
invelia  are  developed  on  the  basis  of  an  embryological  defect. 

'Gliomata  were  formerly  thought  to  be  i^ractically  identical 
with  sarcomata.     It  is  believed  now,  however,  that  they  are  of 
_  epiblastic  origin,  and  like 

~  nerve  cells  are  modifica- 

tions of  epithelial  tissue. 
This  tissue  in  its  normal 
state  is  called  neuroglia. 
It  is  a  nervous  substance. 
It  is  composed  of  small 
cells,  round  or  of  irregu- 
lar shape,  with  a  large 
i-  '^^  ^^\       nucleus  and  fine  fi])rillary 

'v^^^&**-*E**ms«.j»««^-  ^'^       prolongations.    In  glioma 

these  cells  are  relatively 
m  u  c  h  more  numerous, 
while  the  fibrillary  net- 
w^ork  is  less  conspicuous. 
There  is  considerable  va- 
riation in  the  relative 
richness  of  cells  and  fibres, 
however.  When  the  for- 
mer are  very  frequent 
the  term  gliosarcoma  has 
been  wrongly  given  to 
the  tumor.  The  glioma 
is  penetrated  by  small 
blood-vessels  wdiose  walls 
are  often  diseased,  so  that 
minute  hemorrhages  oc- 
cur and  the  glioma  be- 
comes stained  and  pig- 
mented. In  other  cases 
it  is  gray  or  yellowish  in 
color. 

The  rich  cellular  pro- 
liferation in  gliomata  has 
suggested  an  analogy  in 
its  growth  to  that  of  in- 
flammation, and  the  term 
gliosis  is  used  as  analo- 
gous for  neuroglia  to 
inflammation  for  connec- 
tive tissue.  Gliosis  dif- 
fers from  sclerosis,  how- 
ever, in  the  fact  that  in 
the  latter  process  the 
multiplication  of  fibres 
dominates,  wdiile  in  the 
former  it  is  the  cells ;  besides  this,  in  gliosis  there  is  a  tendency 
to  softening  and  formation  of  cavities ;  and  all  nerve  fibres  dis- 
appear. In  sclerosis  some  nerve  fibres  remain,  and  one  observes 
the  presence  of  granular  and  amyloid  bodies. 

Peculiar  Types. — 1.  The  disease  may  be  latent,  giving  rise  to 
very  few  symptoms  or  to  none  that  are  characteristic. 


Fig.  131. 


i^'^'^1^j^^s^:,X 


Fig.  lS-4. 

Figs.  130-132.— Sections  of  Spinal  Cord  at  DrF 

FERENT  Levels  in  Syringo-Myelia  (Bruhl). 


TUMORS   AND   CAVITIES   OF  THE   SPINAL  CORD.        285 


2.  There  may  be  a  period  of  irritation  and  pain  in  the  extrem- 
ities followed  by  paraplegia,  with  few  sensory  troubles,  the  course 
suggesting  a  chronic  transverse  myelitis  or  a  Brown- Sequard 
paralysis. 

3.  There  is  a  type  in  which  bulbar  symptoms  develop  early, 
but  differing  from 
ordinary  bulbar 
paralysis  in  the  in- 
volvement of  the 
trigeminus  and 
other  cranial  nerves 
not  commonly  at- 
tacked. 

4.  There  is  a  form 
characterized  by  a 
rather  rapid  as- 
cending paralysis. 

None  of  these 
types  can  ordina- 
rily be  recogni::ed 
during  life. 

5.  There  is  a  type 
c  h  a  r  a  cterized  by 
the  symptoms  of 
muscular  atrophy 
with  analgesia  and 
felons  (Morvan's 
disease).  In  this 
type  there  is  prob- 
ably a  complicating 
neuritis.  Some  as- 
sert that  all  cases 
of  Morvan's  disease 
are  cases  of  syringo- 
myelia, but  this  is 
not  proven. 

Diagnosis. — The 
disease  is  distin- 
guished in  its  clas- 
sical form  by  (1)  its 
beginning  at  the 
period  of  adoles- 
cence, (2)  by  the 
progressive  muscu- 
lar atrophy  com- 
bined with  the  pe- 
culiar  dissociated 
disturbances  of  sen- 
sibility, (3)  by  the 
t  r  o  p  h  i  c  disturb- 
ances and  scoliosis. 

It  has  to  be  distinguished  from  progressive  muscular  atrophy 
and  dystrophy,  and  amyotrophic  lateral  sclerosis,  hypertrophic 
cervical  pachymeningitis,  chronic  transverse  myelitis,  Morvan  s 
disease  and  anaesthetic  leprosy. 

The  sensorv  and  trophic  disorders  and  scoliosis  enable  one  to 
distinguish  if  from  progressive  muscular  atrophy.     In  leprosy 


Figs, 


Fig. 135. 
133-135.— Sections  op  Spinal  Cord  at  Different 
Levels  in  Syringo-Myelia  (Bruhl). 


286  DISEASES   OF   THE   NERVOUS   SYSTEM. 

the  dissociation  of  the  sensory  symptoms  is  not  present,  and  the 
anaesthesia  is  distributed  along 'the  course  of  the  nerves  or  in 
sharply  circumscribed  plaques.  In  some  cases  the  peculiar  tu- 
bercular disease  of  the  skin  and  the  history  of  the  case  make 
the  diagnosis  easy.  In  leprosy,  also,  there  is  a  perineuritis,  and 
the  enlarged  inflamed  nerves  may  be  felt.  Portions  of  the  skin 
may  be  excised  and  examined  for  the  leprous  bacillus.  As  regards 
the'  differentiation  from  Morvan's  disease,  this  cannot  often  be 
done.  Still  whitlows  are  rare  in  ordinary  forms  of  syringo- 
myelia. Morvan's  disease  begins  in  one  hand  and  slowly  extends, 
with  remissions,  to  the  other.  Usually  there  is  loss  of  tactile  as 
well  as  thermic  and  pain  sense. 

The  prognosis  so  far  as  life  is  concerned  is  bad.  But  the 
disease  has  often  a  long  course,  ranging  from  five  to  twenty  years, 
and  periods  occur  in  Avhich  the  progress  of  the  disease  seems 
arrested  and  improvement  occurs. 

Treatment. — It  is  not  impossible  that  we  may  find  some  drug 
which  acts  specifically  on  gliomatous  tissue,  checking  its  growth. 
At  present  we  know  of  only  two  things  which  may  possibly  do 
this :  nitrate  of  silver  and  arsenic.  These  drugs  should  be  given ; 
and  for  the  rest,  tonic  and  symptomatic  treatment  are  indicated. 


FUNCTIONAL  DISORDERS. 
Spiral  Irritatiox. 

This  name  is  given  to  a  functional  disorder  characterized  by 
great  pain  and  tenderness  along  the  spine  and  associated  with 
a  neurasthenic  and  hysterical  condition.  The  disease  has  been 
described  as  spinal  hypersemia  (Hammond)  and  as  spinal  anaemia. 

Etiology. — Spinal  irritation  is  far  more  frequent  in  women 
than  in  men.  It  occurs  between  the  ages  of  fifteen  and  thirty- 
five  chiefly.  A  neuropathic  constitution  usually  exists.  The 
exciting  causes  are  mental  shocks  and  trauma,  which  latter  need 
be  only  slight;  excessive  physical  and  mental  w^ork  in  young 
people ;  uterine  displacements,  sexual  irritation,  eye  strain ;  and 
sometimes  infectious  fevers.  I  have  seen  cases  which  were  the 
residuum  of  sporadic  cerebro-spinal  meningitis. 

Symptoms.— The  disease  usually  comes  on  slowly,  with  feel- 
ings of  tenderness,  pain,  and  burning  in  the  back.  Walking  in- 
creases this;  sitting  and  using  the  arms  soon  do  the  same.  The 
neck  tires  on  any  exertion;  and  severe  paroxysms  of  a  boring 
neckache  or  of  headache  or  backache  occur.  The  patient  has  to 
lie  down  nearly  all  day,  and  finally  in  bad  cases  remains  in  bed. 
There  are  tender  points  on  each  'side  of  the  spine,  generally  at 
about  the  level  of  the  sixth  cervical,  fourth  to  sixth  dorsal,  and 
dorso-lumbar  junction.  These  points  vary  in  position  and  sensi- 
tiveness. Pressure  on  them  may  cause  nausea,  pulse  disturb- 
ances, parsesthesia,  or  radiating  j^ain.     The  skin  over  the  back  is 


FUNCTIONAL   DISORDERS   OF  THE   SPINAL  CORD.        287 

sensitive,  and  there  may  be  sensitive  points  over  the  ovaries  and 
epigastrium. 

The  reflexes  are  exaggerated ;  there  is  some  motor  weakness, 
and  the  patient  may  be  unable  to  walk,  stand,  or  use  the  arms 
very  much,  but  this  is  due  more  to  the  weariness  and  pain  that 
result  than  to  actual  paralysis.  Some  wasting  occurs  in  the 
limbs,  but  degenerative  reactions  are  never  found.  Occasion- 
ally the  patient  has  cramps  and  twitchings  in  the  extremities. 
Sometimes  there  occurs  in  spinal  irritation  a  nearly  complete 
paraplegia.  This  is  usually  hysterical  and  always  is  functional. 
When  such  a  combination  of  spinal  irritation  and  paraplegia  is 
caused  by  injury,  it  is  called  "concussion  of  the  spine."  Mental 
symptoms  such  as  undue  despondency,  irritability,  nervousness, 
and  emotional  crises  are  often  present.  Neither  hysteria  nor  men- 
tal feebleness,  however,  necessarily  characterizes  spinal  irritation. 
Many  patients  are  unusually  bright,  hopeful,  and  intelligently 
anxious  to  recover.  Sleep  is  usually  poor  and  disturbed  by 
dreams.  The  hands  and  feet  are  often  cold  and  clammy;  the 
pulse  is  rapid  and  of  variable  tension.  The  urine  is  of  light  spe- 
cific gravity,  with  relative  excess  of  phosphates. 

Visceral  symptoms  are  common  in  most  cases.  They  consist 
of  sensations  of  respiratory  oppression,  palpitations,  anorexia, 
nausea  and  vomiting,  constipation  alternating  with  diarrhoea, 
attacks  of  polyuria,  and  sometimes  vesical  and  genital  weakness. 
The  symptoms  are  usually  exaggerated  at  the  menstrual  period. 

The  disease  runs  a  chronic  course;  it  always  lasts  months, 
often  years,  depending  largely  upon  treatment  and  surroundings. 
Some  of  the  symptoms  of  the  trouble  may  remain  for  a  lifetime. 

Pathology.— T\\e  symptoms  of  the  disease  correspond  exactly 
to  what  would  follow  from  an  irritation  of  the  spinal  meninges 
and  posterior  branches  of  the  mixed  spinal  nerves.  Hence  the 
name  spinal  irritation  can  hardly  be  improved  upon  at  present. 
The  fact  that  classical  cases  follow  an  acute  meningitis  leads  me 
to  believe  that  a  hypertemia  generally  underlies  the  condition. 

Diagnosis.— Tliis  must  be  made  from  cervical  caries,  organic 
disease  of  the  spine  and  of  the  cord.  In  caries  the  rigidity,  de- 
formity, and  localized  pain  are  generally  sufficient  helps.  Chronic 
meningitis  is  distinguished  by  the  history  of  an  acute  onset,  the 
symptoms  are  more  stable,  there  is  more  rigidity,  and  the  pains 
are  extrinsic  and  radiating.  The  hysterical  symptoms  are  absent, 
and  the  tendency,  on  rest,  is  always  toward  recovery.  If  there  is 
a  chronic  meningo-myelitis  or  myelitis,  the  paralyses  Avill  be  per- 
haps greater,  and  there  may  be  degenerative  muscular  changes, 
anaesthesia,  and  involvement  of  the  sphincters.  In  a  functional 
palsy  there  cannot  be  complete  degenerative  electrical  reactions 
or  permanent  sphincter  paralyses. 


288  DISEASES  OF  THE  NERVOUS   SYSTEM. 

Prognosis.  —  Xearly  all  cases  get  well  eventu  ally.  Persons  with 
a  weak  will,  feeble  body,  and  neuropathic  constitution  have  the 
worst  outlook.  Traumatic  cases,  if  uncomplicated,  are  not  much 
worse  than  others. 

Treatment. — The  treatment  must  be  a  mental  as  well  as  phy- 
sical one.  The  patient  may  be  put  to  bed  at  first,  but  she  should 
be  kept  employed  and  interested  if  possible,  and  she  should  soon 
be  encouraged  to  walk  and  work  a  little.  Her  surroundings 
should  be  not  too  sympathetic,  and  her  daily  life  should  be  sched- 
uled exactly  for  her.  She  should  be  well  fed,  but  not  stuffed. 
Internally  it  is  customary  to  give  strychnine,  iron,  mineral  acids, 
salicine,  and  quinine  as  tonics ;  moderate  courses  of  bromides  in- 
terrupted at  times,  or  small  doses  of  codeia  and  valerian,  may  be 
used  as  sedatives.  Indian  hemp  and  the  analgesics  may  be  of 
service.  I  have  seen  no  good  from  arsenic,  nitrate  of  silver  or 
gold.  Iodides  and  the  salicylates,  however,  are  useful.  For 
sleeplessness  give  a  draught  of  quassia  water  at  night,  and  make 
the  patient  lie  on  a  hop  pillow  or  inhale  the  steam  from  boiling 
water  in  which  hops  have  been  thrown.  Locally,  counter-irrita- 
tion along  the  back  must  be  kept  up  at  stated  intervals.  For 
this  purpose  one  may  use  mustard,  iodine,  blisters,  the  cautery, 
and  the  galvanic  current.  The  faradic  current  with  a  wire  brush 
is  most  efficacious  for  removing  the  cutaneous  hypersesthesia 
(Anstie)  if  the  patient  can  be  persuaded  to  stand  the  pain. 
Cups,  leeches,  Baumgartism  and  splints,  jackets  and  braces  all 
may  have  to  be  resorted  to  eventually.  A  very  great  deal  de- 
pends upon  the  perseverance  and  personality  of  the  physician. 

Spinal  Exhaustiox  (Spixal  Neurasthexia). 

This  is  a  condition  which  is  nearly  the  opposite  of  spinal  irri- 
tation. It  occurs  as  often  in  men  as  Avomen  and  during  middle 
life  or  the  climacteric. 

Etiology. — It  occurs  oftenest  in  brain-workers  and  the  edu- 
cated classes.  The  principal  exciting  causes  are  shock,  injury, 
overwork,  sexual  excesses,  and  exhausting  diseases. 

The  symjytoms,  which  come  on  slowly,  consist  chiefly  of  a  gen- 
eral motor  weakness  and  condition  of  exhaustion.  The  patient 
cannot  walk  far  or  stand  long.  His  reflexes  are  weak,  the  mus- 
cles get  wasted  and  flabby.  There  are  some  pains  and  burning 
or  creeping  feelings  along  the  back  when  any  exertion  is  made. 
The  stomach  is  weak,  the  bowels  irritable,  the  sexual  power 
nearly  gone.  Headaches,  insomnia,  mental  depression,  and  hypo- 
chondriasis are  present.  The  disease,  in  fact,  presents  many  of 
the  spinal  and  neurasthenic  characters  of  spinal  irritation,  but 
the  pain  is  less  and  the  motor  weakness  much  greater. 


FUNCTIONAL   DISORDERS   OF   THE   SPINAL   CORD.         289 

When  this  latter  reaches  the  point  of  paraplegia  and  follows 
shock  or  injury,  the  trouble  is  also  called  "concussion  of  the 
spine."  Whether  an  anseniia  underlies  it  we  do  not  know.  There 
is  certainly  a  nutritional  defect. 

The  diagnosis,  course,  and  prognosis  are  much  the  same  as  in 
spinal  irritation. 

Treatment. — The  disease  may  be  associated  with  sprains  or 
surgical  injuries  which  need  attention.  Aside  from  this,  the 
treatment  must  be  largely  in  the  nature  of  the  rest  cure.  Mas- 
sive doses  of  tine,  nux  vomica  may  be  used  (ttl  xxx.  to  xl.  t.  i.  d.), 
combined  sometimes  with  a  little  opium  or  codeia.  At  the  same 
time,  electricity,  massage,  baths,  and  strong  feeding  are  required. 
The  patients  usually  improve  on  first  going  under  treatment, 
then  relapse  a  little.  The  physician  must  keep  something  in  re- 
serve for  these  relapses. 


CHAPTER  Xyi. 

ANATOMY  AND   PHYSIOLOGrY  OF  THE  BRAIN. 

Anatomy.— The  nervous  system  is  developed  from  a  hollow 
tube  formed  bv  a  folding  of  the  epiblast.  The  brain  or  enceph- 
alon  grows  out  from  its  anterior  part.  This  swells  into  three 
cavities  called  the  anterior,  middle,  and  posterior  cerebral  vesi- 
cles. From  the  anterior  a  secondary  vesicle  develops ;  the  pos- 
terior divides  into  two :  so  that  eventually  there  are  five  vesicles. 
Out  of  them  the  different  parts  of  the  brain  are  formed. 


Ccrmniss.pcst 
Gland.j)ineal. 


rhugel. 


CereheUum 


hijpcphijsenanla^i 


Fig.  136.  Fig.  137, 

Fig.  186.— The  Cerebral  Vesicles. 

Fig.  137.— Fcrther  Development  of  Vesicles  into  Fore-brain  O^orderhirn), 
TwEEN-BRAiN  (Zwischenhirn),  Mid-brain  (Mittelhirx),  Hind-braik  (Hinter- 
hirn),  and  After-brain  (Nachhirn).  The  cavities  (Hohlen)  of  the  vesicles  are 
being  formed  into  the  ventricles  (Edinger). 

1.  From  the  secondary  anterior  vesicle  there  grow  the  cerebral 
hemispheres,  corpus  callosum,  fornix,  anterior  commissure,  and 
corpus  striatum.     This  forms  the  fore-brain. 

2.  From  the  primary  anterior  vesicle,  the  optic  thalami,  optic 
commissure,  infundibulum,  and  corpora  albicantia.  This  forms 
the  'tween-brain.  The  olfactory  lobes  and  optic  nerves  are  con- 
nected with  this  vesicle. 

3.  From  the  middle  cerel^ral  vesicle  there  grow  the  corpora 
quadrigemina  and  cerebral  peduncles.     This  is  the  mid-brain. 


ANATOMY   AND   PHYSIOLOGY   OF  THE  BRAIN. 


291 


4.  From  the  fourth  vesicle,  the  cerebellum  and  pons.     This  is 
the  hind-brain. 

5.  From  the  fifth  vesicle,  the  medulla,  which  constitutes  the 
after-brain. 

The  development  of  these  parts  is  shown  in  the  accompanying 
diagrams.     In  man  the  fore-brain  is  enormously  developed,  the 


Fig.  138.— Still  Further  Development  of  Vesicles.    The  cerebrum  is  being 
formed  out  of  the  first  vesicle  1^  (Edinger). 

'tween-brain  moderately  developed,  the  olfactory  lobes  atrophic, 
the  mid-brain  almost  rudimentary,  the  hind-brain  well  developed, 
the  after-brain  relatively  not  much  developed.  In  the  process  of 
development  of  the  brain,  the  neural  canal  becomes  variously 
enlarged  and  constricted,  until  the  ventricles  of  the  brain,  the 
foramina  of  Monroe,  and  the  aqueduct  of  Sylvius  are  formed. 
The  ventricles  are  the  two  lateral,  the  third,  fourth,  and  fifth. 


Fig.  139.— Further  Development.     The  dotted  Imes  show  the  oiigmai  sub- 
division into  vesicles  (Edinger). 

The  foramina  of  Monroe  connect  the  lateral  and  third  ven- 
tricles ;  the  aqueduct  of  Sylvius  connects  the  third  and  fourth 
ventricles. 

The  different  segments  of  the  brain  as  thus  enumerated  are 
composed  of  deposits  of  nerve  cells  forming  gray  matter  or  gan- 
glia, and  strands  of  nerve  fibres  connecting  these  ganglia.  Most 
of  the  general  description  of  these  parts  must  be  gotten  from 
treatises  on  anatomy.     I  propose,  however,  to  enumerate  and  de- 


292  DISEASES   OF  THE   NERVOUS   SYSTEM. 

scribe  the  various  ganglionic  deposits  found  in  the  brain;  then 
show  the  way  in  which  they  are  connected  with  each  other  and 
the  spinal  cord. 

The  sixteen  ganglionic  deposits  of  the  brain  are  arranged  in 
the  different  segments  as  shown  here : 

1.  Cerebral  cortex.  ) 

2.  Corpus         ^  Caudate  nucleus.        -  Fore- brain. 

striatum.  "/  Lenticular  nucleus.  ) 

3.  Olfactory  lobes. 

4.  Optic  thalamus.         1 

5.  Corpora  genicalata.  ^  ^t  ween -brain. 

6.  Corpora  mamil.  | 

7.  Luy's  body.  j 

8.  Corpora  quadrigemina.  ) 

9.  Red  nucleus.  >-  Mid-brain. 

10.  Substantia  nigra.  ) 

11.  Cerebellar  cortex.  ) 

12.  Cerebellar  nuclei.  -  Hind-brain. 

13.  Pons  nuclei.  ) 

14.  Olivary  body.     ) 

15.  Nodal  nuclei.      ,-  After-brain. 

16.  Cranial  nuclei.    ) 

The  Cortex  Cerehri  and  the  Convolutions. — The  gray  matter 
of  the  surface  of  the  brain  is  called  the  cortex  cerebri,  and  it  is 
by  far  the  largest  and  most  important  deposit  of  nerve  cells  in 
the  body.  The  cortex  is  from  2  to  4  mm.  (one-twelfth  to  one-fifth 
of  an  inch)  thick,  and  its  total  superficial  area  is  1,800  to  2,700  sq. 
ctm.  The  area  of  gray  matter  lying  in  the  fissures  is  about  twice 
that  lying  on  the  surface  (Donaldson).  The  cerebral  cortex  is 
arranged  in  folds  or  convolutions  (gyri)  separated  by  fissures  or 
sulci.  These  fissures  divide  the  brain  also  into  lobes.  The  fis- 
sures of  the  brain  are  divided  into  primary  and  secondary.  The 
former  are  permanent,  and  present  little  change  in  size,  location, 
or  direction.  The  latter  are  variable  in  all  these  respects,  and 
are  often  called  sulci  for  purposes  of  distinction. 

The  primary  fissures  of  the  brain  are ; 

The  longitudinal. 

The  transverse  or  choroidal. 

The  fissure  of  Rolando  or  central. 

The  fissure  of  Sylvius. 

The  parietal. 

The  parieto-occipital. 

The  calcarine. 

The  position  of  these  fissures  is  indicated  on  the  accompany- 
ing diagrams,  which  are  based  on  descriptions  of  Wernicke,  Eber- 
staller,  Wilder,  Cunningham,  and  many  observations  of  my  own. 
I  have  not  space  to  give  detailed  descriptions. 

The  secondary  fissures  or  sulci  will  be  enumerated  in  describ- 
ing the  lobes.  They  are  divided  into  the  typical  or  more  or  less 
constant  and  the  atypical  or  tertiary  fissures. 

The  primary  fissures  divide  the  cerebrum  into  various  por- 
tions called  lobes.     The  lobes  are : 

Frontal.  The  central  or  island  of  Reil. 

Parietal.  Olfactory. 

Temporal.  Limbic. 

Occipital. 


ANATOMY  AND   PHYSIOLOGY   OF   THE   BRAIN 


293 


e  1  T'  :S  ^  a.  ^  .s  •?: 


"S   i 


S  r  i  §  -  S  ^  Si 

■^  ^  "    rt    Si    rt  -^    '-"    .- 
;:  3  -g  s  ^  .'^  ^-  s 

p.  -2  -g^  &c  o   a   aj   a 
°,  -J   P  fi;  5   8   S  2 


294  DISEASES   OF  THE  NERVOUS  SYSTEM. 

There  are  eight  fissures  and  seven  lobes. 

TJie  frontal  lobe  is  limited  behind  by  the  fissure  of  Rolando, 
and  on  the  median  surface  by  the  calloso-marginal  or  subfrontal 
fissure  and  its  ascending-  brancii.  It  has  the  following  sulci;  1. 
Superior  frontal  and  superior  prsecentral.  2.  Inferior  frontal  and 
inferior  prcecentral.     3.  Olfactory.     4.  Tri-radiate. 

In  the  frontal  lobe  are  the  following  convolutions.  1.  Prsecen- 
tral  or  ascending  frontal,  having  on  its  median  surface  (a)  the 
paracentral  lobule.  2.  First  or  superior  frontal.  3.  Second  or 
middle  frontal.     4.  Third  or  inferior  frontal  (Fig.  140). 

The  jmrietal  lobe  is  limited  behind  by  the  parieto-occipital 
and  anterior  occipital  fissures,  below  on  its  outer  surface  by  the 
Sylvian  fissure  and  a  line  drawn  back  from  its  upper  end  to  the 
lower  part  of  the  anterior  occipital.  In  front  it  is  limited  by  the 
fissure  of  Rolando.  On  its  median  surface  it  is  limited  in  front 
by  the  ascending  branch  of  the  calloso-marginal  or  subfrontal 
fissure,  behind  by  the  parieto-occipital,  and  below  by  the  sub- 
parietal  fissure.  Its  important  sulci  are:  1.  The  parietal  or  inter- 
parietal. 2.  The  post-central.  The  convolutions  formed  are,  on 
the  convex  surface:  1.  The  post-central   or  ascending  parietal. 

2.  The  superior  i^arietal  lobule,  having  on  its  median  surface  (a) 
the  quadrate  lobule  or  prsecuneus.  3,  The  inferior  parietal  lobule, 
which  is  composed  of  {a)  the-&upra_zBiaTgjnal  gyrus,  (b)  the  angu- 
lar gyrus.  Tliese  latter  gyri  are  variously  described,  but  it  is  best 
to  regard  one,  (a)  the  supra-marginal,  as  that  surrounding  the 
posterior  end  of  the  fissure  of  Sylvius ;  the  other,  (b)  tho^^xxgjilsir, 
as  that  beginning  at  the~iTpper^iknrr~oniie  first  teJi^iporal  fissure 
and  extending  back  as  far  as  the  anterior  occipital  fissure. 

The  Occij^itaJ  Lobe. — This  is  limited  on  its  convex  surface, 
anteriorly,  by  the  parieto-occipital  fissure,  laterally  to  this  by 
the  anterior  occipital  and  inferior  occipital  fissures.  These  in  apes 
form  a  single  continuous  fissure  sharply  separating  the  occip- 
ital from  the  other  lobes.*  On  its  median  surface  the  parieto- 
occipital fissure  limits  the  lobe  in  front.  On  the  under  surface 
the  anterior  edge  of  the  tentorium  about  marks  the  anterior 
limit. 

The  sulci  are:  1.  The  transverse  occipital  (sipe  fissure  of  some 
writei's).  2.  The  superior  or  lateral  occipital.  3.  The  inferior 
occipital.  On  the  median  surface :  4.  The  calcarine,  which  joins 
the  parieto-occipital.  5.  The  inferior  occipito-temporal  or  fourth 
temporal. 

The  convolutions  on  the  convex  surface  are  -.  1.  The  superior 
occipital.  2.  The  middle  occipital.  3.  The  inferior  occipital.  4. 
The  descending  occipital.  On  the  median  surface  we  find:  5. 
The  cuneus.     0.  Descending  occipital. 

The  Temporal  Lobe. — The  convex  or,  lateral  surface  shows  the 
following  sulci :  1.  The  first  temporal  or  parallel  sulcus.  2.  The 
second  or  middle  sulcus.     On  the  under  and  median  surfaces  are : 

3.  The  third  or  inferior  temporal  sulcus.  4.  The  fourth  temporal 
or  inferior  occipito-temporal  or  collateral  sulcus,  which  extends 
into  the  occipital  lobe.     5.  The  hippocampal  sulcus. 

The  convolutions  are:  1.  The  first  temporal  convolution.  2. 
The  second  temporal  convolution.  •  3.  The  third  temporal  con- 
volution. 4.  The  lateral  occipito-temporal  or  fusiform  convo- 
lution. 5.  The  median  occipito-temporal  or  lingual  convolu- 
tion.  6.  The  hippocampal  convolution,  which  is  an  extension  of 
*  There  is  still  some  doubt  about  the  homology  of  these  tissues. 


ANATOMY   AND   PHYSIOLOGY   OF   THE   BRAIN. 


295 


4  and  5.     7.  The  uncinate  convolution,  which  is  an  extension 
of  6. 

The  Island  of  Reil  (lobus  centraUs,  lobus  caudicis). — This  has 
a  circular  sulcus  surrounding  it,  and  several  more  or  less  short 
sulci  dividing  it  into  from  five  to  seven  short  gyri. 

The  limbic  lobe,  if  described  as  a  separate  lobe,  is  made  to  in- 
clude anteriorly  the  gyrus  fornicatus  or  gyrus  cinguli,  back  of 
this  the  isthmus,  then  the  hippo- 
campal,  uncinate,  and  dentate  con- 
volutions (Fig,  140). 

The  olfactory  lobe  is  rudimen- 
tary in  man.  Its  position  is  shown 
in  the  diagrams. 

The  operculum  is  the  part  of  the 
brain  that  overlaps  the  island  of  i  iw_JL4aiii  \ 

Reil.      It  consists  of  a  fronto-pari- 
etal  part,  formed  by  the  lower  end 


s  Mf  '.  .f 


Fig.  14;^. 


i^ic   141 

Fig.  141.— Section  of  Cortex  of  Frontal  Lobe  Stained  by  Weigert's  Method, 
showing  the  fibre  systems  and  laj^ers.  1,  2,  3,  4,  The  ganglionic  cell  layers ;  a, 
neuroglia  layer;  6,  tangential  fibres;  c,  super-radial  network;  d,  outer  stripe  of 
Baillarger  or  Glennari's  stripe ;  e,  inter-radial  network  ;  /,  inner  stripe  of  Bail- 
larger;  g,  radial  fibres  of  white  matter  (after  Obersteiner  and  Edinger). 

Fig.  142.— Section  of  Cortex  of  Frontal  Lobe  (after  Golgi).  1,  Neuroglia 
or  barren  layer  ;  2,  small  pyramidal  layer;  3,  large  pyramidal  layer;  4,  irregular 
and  spindle-cell  layer.  At  G^,  a  deposit  of  granular  cells  forms  a  fifth  layer  in  the 
sensory  occipital  area  of  the  cortex. 


296  DISEASES   OF  THE  NERVOUS   SYSTEM. 

of  the  two  central  convolutions,  a  frontal  part  formed  by  the 
base  of  the  inferior  frontal  convolution,  and  a  temporal  part 
formed  bv  the  tip  of  the  temporal  lobe. 

The  cuneus,  prcccuneus  and  paracentral  lobule  are  important 
subdivisions  on  the  median  surface  of  the  brain.  Their  position 
and  boundaries  are  shown  in  the  cuts. 

Micioscopical  Anatomy  of  the  Convolutions.— T\ie  cortex  of 
the  cerebrum  is  composed  of  nerve  cells,  a  network  of  nerve 
fibres  and  processes,  and  of  neuroglia  tissue.  Superimposed  upon 
it  is  a  very  vascular  membrane,  the  pia  mater,  which  sends  a  rich 
plexus  of'  vessels  into  it.  We  shall  proceed  to  study :  1st,  the 
structure  and  arrangement  of  the  nerve  and  neuroglia  cells ;  2d, 
the  arrangement  and  connections  of  the  nerve  plexuses.  On 
both  these  points  new  facts  are  being  constantly  added,  and  the 
present  description  must  be  in  many  respects  only  provisional. 
1st.  The  cells  are  arranged  to  a  certain  extent  in  layers.  In  the 
outer  laver,  next  the  pia  mater,  is  a  deposit  of  neuroglia  tissue 
containing  "spider  cells.''  Beneath  these  are  small,  somewhat 
irregularlv  shaped  pyramidal  cells  (angular  cells  of  Lewis);  next 
come  large  pyramidal  cells ;  and  deepest  of  all  irregularly  shaped 
cells  (including  the  granule  cells  of  Lewis)  and  spindle-shaped 
cells. 

In  the  above  I  have  described  four  layers  of  cells,  and  this 
mav  be  considered  the  type.  Some  anatomists  describe  five  typi- 
callayers,  the  fifth  being  made  by  a  subdivision  of  the  fourth 
(by  Meynert)  or  of  the  third  (by  Lewis).  The  common  four-layer 
type  is  found  in  the  central  convolutions  and  frontal  lobe.  In 
the  occipital  region  there  are  six  (Lewis)  or  eight  (Meynert)  layers 
described.  These  are  formed  by  the  interposition  of  granule 
cells  which  subdivide  the  third  layer.  Various  tj^pes  of  cortex 
are  described  depending  upon  the"^  different  degree  of  develop- 
ment of  the  cell  layers  and  upon  the  fibre  arrangements.  The 
common  or  motor  type,  as  has  been  stated,  has  four  layers.  The 
large  pyramidal  cells  are  here  numerous  and  are  arranged  in 
clusters.  The  sensory  type  has  at  least  five  layers,  as  described 
for  the  occipital  cortex,'  and  here  the  large  j)yramidal  cells  are 
few  and  isolated.  The  pyramidal  cells  are  arranged  with  their 
apices  pointing  to  the  periphery.  They  give  off  apical,  lateral, 
and  basal  processes.  The  basal  process  of  the  pyramidal  cells  is 
continued  as  an  axis  cylinder.  Some  pass  down  into  the  white 
matter;  others  turn  up  and  enter  the  fibre  systems  of  the  cortex. 
The  spindle  cells  point  toward  the  periphery  also,  except  at  the 
bottom  of  the  sulci,  where  they  lie  parallel  to  the  surface.  Their 
processes  connect  neighboring  areas  and  are  called  associative 
fibres. 

The  small  pyramidal  and  spindle  cells  measure  about  10  xl8//; 
the  large,  20  x  40,//  (y^ott  x  ^^q  in.).  There  are  in  the  upper  central 
and  paracentral  convolutions  giant  cells  (of  Betz)  which  measure 
125  X  55//  (  Yrro  X  5^Tj  in.). 

Despite  the  great  variety  a.nd  complexity  of  the  cortex,  it  is 
probable  that  there  are  but  three  principal  classes  of  cells  :(1) 
those  which  receive  nervous  impulses 'and  which  lie  chiefly  in  the 
second  and  granule  layers;  (2)  those  Avhich  associate  and  co- 
ordinate these  impulses,  and  which  lie  in  the  second  and  deep  in 
the  fourth  layers  (small  pyramidal  and  spindle  cells) ;  and  (3)  those 
which  discharge  impulses  and  which  lie  in  the  third  layer  (large 
pyramidal  cells). 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN.  297 

The  fibres  and  plexuses  oi  the  cortex  are  composed  of  processes 
from  the  nerve  cells  and  terminals  coming  in  from  the  white  mat- 
ter. They  collect  into  several  close  networks.  One,  lying  just 
under  the  neuroglia  layer  and  running  parallel  to  the  surface,  is 
called  the  tangential  layer  of  fibres ;  a  second  layer  runs  among 
the  large  pyramidal  cells,  forming  the  outer  stripe  of  Baillarger; 
and  a  third  layer,  beneath  this,  is  called  the  inner  stripe  of  Bail- 
larger.  Besides  these,  there  are  radiating  fibres,  running  in  from 
the  white  matter  and  forming  inter-radial  and  supra-radial  net- 
works (Fig.  142). 

The  cortical  gray  matter,  as  will  thus  be  seen,  contains  layers 
of  nerve  cells,  into  which  nerve  fibres  penetrate.  These  termi- 
nate, as  do  all  fibres,  in  end-brushes,  which  surround  the  receptive 


Fig.  143.— DiAGRAMATic  Rkpresentatiun  of  the  Relation  of  the  Cells  op 
THE  Cortex  to  Each  Other  and  to  Distant  Parts.  A,  Motor  type  of  cortex.  1, 
Neuroglia  cell;  2,  small  pyramidal  and  granule  cell;  3,  large  pyramidal  cell;  4,  spin- 
dle cell;  o,  tangential  fibres;  6,  stripes  of  Baillarger;  c,  associative  fibres.  B,  Sensory 
type  of  cortex  (Von  Monakoff).  II.,  III.,  V.,  Second,  third,  and  fifth  layers  of  cor- 
tex; hx\  large  pyramidal  cell;  sx,  granule  cells.  In  A,  impulses  are  received  by  the 
small  cells  2,  distributed  and  associated  by  the  tangential  and  other  fibres  a,  b,  c 
and  by  the  spindle  cells  4;  impulses  are  emitted  by  the  large  cells  3. 

or  sensory  cells.  An  enormous  number  of  fine  fi  bres  are  given 
off  by  the  cells ;  some  of  these  form  layers  in  the  cortex  and  con- 
nect "neighboring  parts,  others  run  out  and  connect  more  distant 
parts  or  pass  down  to  lower  levels.  There  must  be  three  kinds 
of  fibres— afferent,  associative,  and  efferent— just  as  there  are 
three  types  of  cells  (Fig.  143). 

The  different  convolutions  and  lobes  of  the  brain  are  connected 
with  each  other  by  association  fibres  and  with  parts  below  by 
projection  fibres. 

The  association  fibres  consist  of  short  fibres  connecting  neigh- 
boring convolutions,  long  fibres  connecting  neighboring  or  dis- 
tant lobes,  and  commissural  fibres  connecting  the  two  halves  ot 
the  cerebrum. 


298 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


The  short  association  fibres  are  numerous ;  they  lie  close  be- 
neath  the  gray  matter  and  connect  convolutions  of  the  same 
lobes.  The  course  of  many  of  the  long  association  paths  is  not 
yet  well  known,  the  descriptions  commonly  given  being  not  alto- 
gether correct  (H.  Sachs).  The  occipital  lobe  is  connected  by 
long  tracts  to  the  temporal  lobe,  and  perhaps  slightly  to  the  in- 
ferior i^arietal  lobe  (H.  Sachs).  The  temporal  lobes  are  con- 
nected only  to  the  occipital.  The  frontal  lobe  is  apparently 
connected  with  the  parietal.  Its  connection  with  the  temporal 
is  denied  (H,  Sachs).  All  the  lobes  of  the  two  halves  of  the  brain 
are  connected  with  each  other  by  commissural  tracts  in  the  cor- 
pus callosum  and  anterior  commissures. 


-^ 


^ 


>r 


^y^ 


Fig.  144. 


-Nerve  Cells  of  Corpus  Striatum  with  Processes   Running  into 
Internal  Capsule. 


I  will  describe  the  projection  fibres  later. 

The  corpora  striata  are  composed  of  two  parts-  the  caudate 
nucleus  and  lenticular  nucleus.  These  two  nuclei  are  separated 
dorsally  by  the  white  fibres  forming  the  internal  capsule.  Below 
they  are  continuous.  Their  shape  and  relations  are  not  easily 
appreciated  except  by  actual  inspection  of  specimens.  They  are 
indicated  in  the  accompanying  figures  (148-150).  The  head  o'f  the 
caudate  nucleus  is  connected  with  the  grav  matter  of  the  anterior 
perforated  space.  The  tail  extends  into  the  temporal  lobe,  where 
it  is  continuous  with  the  gray  matter  of  the  cortex,  called  at  this 
point  the  amygdalum,  and  with  the  claustrum. 

The  lenticular  nucleus  is  also  continuous  with  the  grav  matter 
of  the  anterior  perforated  space.  It  is  divided  into  three  por- 
tions; the  external  is  called  the  putamen,  the  two  inner  the 
globus  pallidus.  These.rparts  are  separated  bv  white  fibres.  The 
caudate  nucleus,  putamen,  and  probably  all  of  the  corpus  striatum 
are  modifications  of  the  cerebral  cortex. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  BRAIN. 


299 


The  corpus  striatum  has  (1)  fibres  which  pass  to  it  horn  the 
cortex,  (2)  fibres  which  pass  through  it  from  the  frontal  and  parie- 
tal cortex,  (3)  fibres  which  originate  in  it,  and  (4)  fibres  connect- 
ing its  different  parts. 

1.  The  fibres  joining  the  ganghon  to  the  cortex  are  few  and 
merely  associativ^e. 

2.  The  fibres  which  pass  through  it  pass  chiefly  into  the  dorsal 
part  of  the  cerebral  peduncles  (or  tegmentum)  and  are  connected 
with  the  sensory  tracts  there. 

3.  Fibres  which  originate  in  the  caudate  nucleus  and  putamen 
collect   together  and  join  with  the  cortical  fibres  to  form  the 


Fig.  145. — Showing  the  Relations  op  the  Optic  Thalamus  to  Other  Parts 

(Edinger). 

"  lenticular  loop "  (ansa  lenticularis).  Some  go  to  the  subthal- 
amus  (Luy's  body)  and  optic  thalamus;  most  go  to  the  inferior 
olives  and  thence  connect  with  the  cerebellum.  Some  perhaps 
go  to  the  posterior  longitudinal  bundle,  which  is  a  band  of  com- 
missural fibres  that  connect  together  the  cranial  nerve  nuclei  in 
the  medulla. 

4.  Fibres  connect  the  caudate  nucleus  and  putamen  with  the 
globus  pallidus. 

The  corpora  striata  are  relatively  rudimentary  ganglia  in  man. 
They  contain  sparsely  distributed'^multipolar  and  fusiform  cells, 
YsVo  to  5^0  in.  in  diameter,  the  larger  being  in  the  lenticular 
nucleus.     They  are  chiefiy  of  the  sensory  type  (Marchi— Fig.  144). 

The  Optic  fJi  al  a  mi.— The^e  ganglia  form  the  chief  part  of  the 
'tween-brain.    They  lie  at  the  base  of  the  brain,  posterior  and  in- 


300 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


ternal  to  the  corpora  striata.  They  are  continuous  with  each 
other  bv  means  of  the  middle  gray  commissure.  The  upper  or 
dorsal  surface  forms  part  of  the  wall  of  the  lateral  ventricles ;  the 
mesial  surface  forms  the  lateral  wall  of  the  third  ventricle.  Ex- 
ternally is  The  band  of  white  fibres  called  the  internal  capsule; 
below  this  is  a  rather  large  mass,  the  red  nucleus,  external  to  a 
small  grav  nucleus  called  the  subthalamic  ganglion  (Luy"s  body). 
Around  and  below  these  is  a  complex  network  of  fibres  called  the 
stratum  intermedium.  Below  this,  on  the  base  of  the  brain,  are 
the  corpora  mamillaria.  The  thalamus  is  composed  of  four  niiclei 
—the  anterior,  lateral,  and  median  or  posterior.  The  last  is  called 
the  pulvinar.  Besides  these  there  is  on  the  median  surface  a 
small  ganglion  called  the  g.  habenulse.  The  optic  tracts  wind 
around  the  posterior  and  outer  edge  of  the  thalamus ;  and  con- 
nected with  these  and  the  thalamus  are  two  other  ganglia,  the 


Fig.  146.— Nerve  Cells  op  Optic  Thalamus  (Marchi). 


external  or  lateral  and  internal  or  median  geniculate  bodies. 
Thus  the  thalamus  is  in  close  anatomical  relations  with  five 
small  ganglia;  three  below  it — the  corpus  mamillare,  red  nucleus, 
and  subthalamus ;  two  postero-external  to  it,  the  geniculate  bodies. 
To  these  may  be  added  the  corpora  quadrigemina.  The  thala- 
mus is  composed  of  multijDolar  nerve  cells  rather  more  numerous 
and  larger  than  in  the  striatum,  but  not  grouped  closely  together. 
Xerve  fibres  pass  in  among  these  cells,  which  are  said  (Marchi)  to 
be  of  the  motor  type  (Figs.  145,  146). 

The  Corpora  Quadrigemina.— The  mid-brain  contains  as  its 
chief  ganglia  the  corpora  quadrigemina.'  These  consist  of  four  tu- 
bercles, two  anterior  and  two  posterior  (Fig.  145).  In  man  they 
are  rudimentary  in  structure  and  relatively  unimportant  in  func- 
tion. In  man  also  the  posterior  tubercles  are  developed  more  rela- 
tively than  in  most  lower  animals.  They  together  measure  about 
14  mm.  {I  in.)  in  sagittal  direction.  In  front  lies  the  pineal  gland 
and  third  ventricle;  beneath  is  the  aqueduct  of  Sylvius  and  the 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN. 


301 


structures  of  the  upper  pons  and  cerebral  peduncles.    This  inferior 
boundary  is  shown  by  the  dotted  line  in  the  cut  (Fig.  147).     Micro- 


rotj 


Fig.  147.— Section  Through  the  Corpora  Quadrigemina  (Q),  Tegmentum  (TG), 
AND  Cerebral  Peduncles.  SS,  Substantia  nigra;  Pp,  peduncles;  AS,  aqueduct  of 
Sylvius. 

scopically  the  anterior  lobes  consist  of  layers  suggesting  a  cortical 
type  (Spitzka) ;  the  outermost  is  made  up  of  optic-tract  fibres,  the 
next  is  a  thin  layer  of  small  nerve  cells,  then  optic  fibres  again, 


Fig.  148.— Longitudinal  Section,  showing  the  lenticular  {In)  and  caudate  nuc/oi 
icn)  separated  by  the  internal  capsule  (ic).  the  corpus  callosum  ice),  the  anterior 
commissure  iac),  the  optic  tract  (II.),  the  optic  thalamus  (fii),  the  corpora  genicu- 
lata  Cff),  and  the  pulvinar  (p),  the  crusta  icr),  the  tegmentum  (jLg),  pons  (P),  and 
cerebellum  (C);  p,  putamen  ;  gr,  globus  pallodus  (G.  Stewart). 

and  deepest  of  all  a  layer  containing  a  few  large  cells.  The  pos- 
terior lobes  are  more  homogeneous  and  contain  small  multipolar 
cells  and  a  ganglion. 


302  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  accompanying  figures  show  the  relationships  of  the  basal 
ganglia  and  other  parts. 

The  Substantia  JSigra.— Below  the  corpora  quadrigemina  and 
lying  between  the  upper,  sensory  part  {tegmentum)  of  the  pedun- 
cles ^of  the  brain  and  the  lower  motor  part  (crusta)  is  the  sub- 
stantia nigra.  It  contains  large  multipolar,  angular,  and  fusiform 
cells  deeply  pigmented  (Fig.  147).  ,       .  .. 

The  Med  Nucleus.— Dorsal  to  the  s.   nigra  and  at  about  its 


Fig.  149.— Horizontal  Section,  showing  the  frontal  (F),  temporo-sphenoidal  (TS\ 
and  occipital  lobes  (O),  with  their  gray  and  white  matter,  the  island  of  Reil  (R),  its 
gray  and  white  substance,  the  claustrum  (cO,  the  external  capsule  (ec),  the  lenticu- 
lar nucleus  (hi),  the  caudate  nucleus  (oi),  the  internal  capsule  (ic),  the  optic  thalamus 
QtJi),  and  pulvinar  (p),  the  corpus  callosum  ice),  the  anterior  and  posterior  commis- 
sures iac  and  pc),  the  lateral  ventricle  (LV),  with  the  choroid  plexus  (ch)  (G. 
Stewart). 

middle  extent  is  the  red  nucleus.  It  is  spherical  or  oblong,  very 
vascular,  and  contains  numerous  sm^ll  cells. 

The  suhthalamus  (Luy's  body)  lies  more  dorsally,  but  in  about 
the  same  plane  as  the  substantia  nigra.  It  measures  about  i  by  i 
inch  and  contains  a  few  cells  and  a  very  fine  plexus  of  nerve  fibres. 

The  position  and  relation  of  these  bodies  are  shown  in  Figs. 
156-158. 

The  nuclei  of  the  pons  varolii  are    irregularly  distributed 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN.  303 

masses  of  nerve  cells  lying  deep  among  the  longitudinal  and 
transverse  fibres.  A  special  nucleus  lying  low  down  in  the  pons 
is  known  as  the  superior  olive.  In  the  after-brain  or  medulla 
we  have  the  gray  matter  of  the  floor  of  the  fourth  ventricle  and 
its  cranial  nerve  nuclei,  the  olivary  bodies,  and  certain  small  de- 
posits of  gray  matter  called  the  nodal  niuilei. 

The  cerebellum  in  man  consists  of  a  median  portion  or  vermis 
and  two  lateral  hemispheres.  It  is  connected  to  the  cord  and 
rest  of  the  brain  by  anterior,  middle,  and  posterior  peduncles. 
It  is  composed  of  an  external  layer  or  cortex  of  gray  matter,  of 
white  matter,  and  central  ganglia.  The  gray  matter  lies  in  very 
close,  narrow  folds,  producing  with  the  white  matter  an  appear- 


FiG.  150.— Section  Through  the  Middle  of  the  Basal  Ganglia,  Pr^central 
(AF)  and  Part  op  Post-Central  (AP)  Convolutions,  and  (TS)  Temporal  Lobe. 
It  shows  the  corpus  callosum  (cc),  the  fornix  (6),  the  fifth  ventricle  (v),  lateral  ventri- 
cles (LV),  small  part  of  thalamus  (f/i),  internal  capsule  (ic),  caudate  nucleus  (en), 
lenticular  nucleus  {In),  external  capsule  (ec),  claustrum  (ec)  (6.  Stewart). 

ance  on  section  called  the  arbor  mice.  The  vermis  and  hemi- 
spheres are  divided  by  sulci  into  a  number  of  lobes  and  lobules. 
The  vermis  is  divided  into  superior  and  inferior  portions.  Its 
further  subdivisions  and  those  of  the  hemispheres  are  shown  in 
the  cuts  (Figs.  151,  153). 

In  the  white  matter  of  either  hemisphere  is  a  nucleus  of  small 
multipolar  cells,  the  corpus  dentatus  or  ciliary  body.  To  the 
median  side  of  this,  and  belonging  structurally  to  it,  is  a  small 
nucleus,  the  emboliform  nucleus.  In  the  inferior  vermis  is  a 
collection  of  larger  multipolar  cells,  the  nucleus  fastigium  or 
tegmental  nucleus;  just  to  the  outer  side,  between  it  and  the 
emboliform  nucleus,  is  a  small  collection  of  cells,  resembling 
those  of  the  ii.  fastigii,  called  the  nucleus  globosus. 

The  cortex  of  the  cerebellum  is  divided  from  within  out  mto 


304 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


a  granular  layer,  a  layer  of  large  cells,  and  a  molecular  layer. 
The  granular  layer  is  coraposed  of  minute  round  cells  and  larger 
or  Purkinje  cells  with  processes.  The  cells  are  all  of  nervous 
character;  possibly  some  belong  to  the  neuroglia  tissue.     They 


:,....  J 

Fig.  151.— Showing  the  Lobes  xkd  Other  Subdivisions  of  the  Cerebellum.  Dorsal 
Surface  (Edinger). 

send  up  processes  into  the  molecular  layer,  and  some  end  in  a 
network  around  the  Purkinje  cell.  The  large  or  Purkinje  cells 
(20  X  30  ^)  have  very  rich  branching  processes  running  up  into 
the  molecular  layer  as  far  as  the  periphery,  where  they  turn 
down,  and  an  axis-cylinder  process  running  down  into  the 
white  matter.     The  processes  do  not  anastomose  and  the  cells 


Fig.  152.— Cerebellum,  Ventral  Surface  (Edinger). 

are  not  pigmented.  The  molecular  layer  contains  large  and 
small  cells,  some  of  which  are  multipolar,  and  send  processes 
which  end  in  a  basket-work  plexus  around  the  Purkinje  cells. 
Fibres  coming  in  from  the  white  matter  appear  to  terminate  also 
in  end-brushes  around  these  cells  (Fig.  154— Cajal).     The  fibres  of 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN. 


305 


the  cortex  are,  as  in  the  cerebrum,  radiating  and  tangential.  The 
tangential  fibres  are  at  the  level  of  the  Purkinje  cells,  among  the 
processes  of  which  they  run.  Just  beneath  the  pia  is  a  thin 
connective  or  neuroglia  tissue  membrane  which  sends  radial  fibres 
down  through  the  gray  matter,  affording  it  a  support. 

It  will  be  seen  that  the  general  arrangement  of  the  cerebellar 
cortex  is  analogous  to  that  of  the  cerebrum.  Associative  and  re- 
ceptive cells  are  found  in  the  granular  and  molecular  layers,  and 
they  send  processes  forming  a  rich  network  around  Purkinje's 
cells  which  are  efferent  in  function.  The  comparatively  small 
number  of  the  large  cells  is  in  harmony  with  the  view  that  the 
cerebellum  is  an  organ  that  receives  and  adjusts  nerve  impulses 
for  co-ordinate  distribution.  All  parts  of  the  cerebellar  cortex 
are  anatomically  alike. 


Fig.  153.  Fig.  154. 

Fig.  153.— Section  Through  Middle  of  Vermis  and  Pons. 

Fig.  154.— Cerebellar  Cortex  of  Embryo.  D,  Furkinje"s  cell ;  G,  granule 
cell  receiving  a  fibre  and  sending  an  end-brush  or  arborization  to  the  P,  Purkinje's 
cell  (Cajal). 


The  white  matter  of  the  cerebellum  consists  of  nerve  fibres 
some  of  which  go  to  form  the  peduncles.  Others  form  anterior 
and  posterior  commissures  running  through  the  two  extremities 
of  the  vermis  and  connecting  the  hemispheres.  There  is  also  a 
longitudinal  commissure  in  the  vermis.  The  white  matter  around 
the  corpus  dentatum  is  called  the  fleece. 

Having  described  the  general  arrangement  of  the  different 
divisions  of  the  brain  and  the  collections  of  gray  matter  found  in 
them,  we  are  prepared  to  study  the  tracts  of  white  matter 
which  connect  the  different  parts. 

The  white  matter,  as  already  shown,  is  made  up  of : 
(  Short. 

1.  Association  fibres.  <  Long. 

(  Commissural. 

2.  Projection  fibres. 


306 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


1.  The  association  fibres  of  the  cortex  have  been  already  de- 
scribed. Besides  tiiese,  there  are  association  fibres  connectin*^ 
different  ganglia  of  lower  levels.  They  are  named  .  Yicq  d'Azyr's 
bundle,  the  fasciculus  retroflexus  or  Meynerfs  bundle,  the  teg- 
mental bundle,  the  brachia  of  the  corpora  quadrigemina  and  the 
posterior  commissure.  These  may  be  called  ganglionic  associa- 
tion tracts.  Some  of  these  will  be  described  later  and  indicated 
in  the  figures. 

Commissural  association  fibres  connect  similar  and  symmetri- 
cal anatomical  levels.     They  are  the  corpus  callosum,  the  anterior 


Fig.  155.— Sections  of  Cortex  of  Same,  but  Older.  A,  Neuroglia  layer  ;  B,  zone 
of  bipolar  cells;  C,  molecular  layer;  D,  granular  layer;  e,/,^.  bipolar  ceUs  of  molecular 
layer  ;  j,  o,  y,  n,  fibres  from  the  white  matter  which  end  in  end-brushes  or  arboriza- 
tions capping  the  cells  of  Purkinje  ;  h,  Pm'kinje  ceU  with  axis  cylinder  and  collateral. 

and  middle  commissures,  the  fornix,  and  the  anterior  and  pos- 
terior cerebellar  commissures. 

2.  T\\e  projection  fibres  £ive  long  tracts  which  connect  higher 
with  lower  levels.  Some  of  them  have  a  long  and  some  an  inter- 
rupted course.  The  long  projection  fibres  extend  from  the  fron- 
tal and  parietal  cortex  down  into  the  spinal  cord.  They  pass  as 
a  narrow  band  of  fibres  between  the  lenticular  nucleus  and  the 
caudate  nucleus,  helping  to  form  theintenial  capsule;  thence  into 
the  lower  part  of  the  cerebral  peduncle,  forming  the  crusta ;  thence 
through  the  i:)ons  and  medulla.  At  the  lower  part  of  the  medulla 
they  form  the  anterior  pyramids.  About  90  per  cent  of  the  pyr- 
amids crosses  over  and  passes  down  in  the  lateral  columns  as  the 
crossed  pyramidal  tract ;  the  other  ten  are  continued  down  in 


ANATOMY  AND  PHYSIOLOGY  OF  THE  BRAIN. 


;07 


the  anterior  column  as  the  direct  pj^ramidal  tract.  Its  fibres 
cross  over  in  the  anterior  commissure.  Both  tracts  connect  with 
the  cells  of  the  anterior  horns.  The  entire  traject  of  fibres  from 
the  cortex  cerebri  to  the  anterior  horns  forms  tlie  voluntary  motor 
tract. 

The  interrupted  projection  fibres  consist  of  the  sensory  tracts 
and  the  cerebro-pontine  tracts.  The  sensory  tracts  starting  from 
the  brain  cortex  in  part  connect  with  the  thalamus,  in  part  pass 
directly  through  the  posterior  portion  of  the  internal  capsule,  then 
through  the  upper  part  of  the  cerebral  peduncles,  forming  there 
the  tegmentum,  and  thence  through  the  pons  and  medulla  as  the 
lemniscus  and  formatio  reticularis.  In  the  medulla  some  fibres 
cross  over,  forming  a  "  sensory  decussation,"  and  end  in  the  nuclei 
of  the  columns  of  Goll  and  i3urdach ;  others  run  in  the  formatio 
reticularis,  pass  down  in  the  posterior  and  lateral  columns,  cross 


,\_^.  Goll. 

C.  Burdadv. 

^^D  C.  Tract 
Fig,  156.— a,  Connections  of  spinal  cord  with  pons  and  medulla  ;  N,  nodal  nuclei; 
O,  olivary  body  ;  PN,  pons  nuclei  ;   L.  lemniscus  ;  3  to  12,  cranial  nuclei ;  x,  decussa- 
tion ;  ST,  Sensory  tracts  ;  AFC,  anterior  fundamental  colimins  ;  LFC,  lateral  fund, 
cols. :  DC,  direct  cerebellar  tract. 


over  at  various  levels,  and  connect  with  cells  of  the  posterior 
horns.     The  cerebro-pontine  tracts  are  described  under  Fig.  158. 

Architecture  of  the  Brahi.— The  relations  of  the  ganglionic 
deposits  of  the  brain  with  the  cord  and  with  each  other  cannot 
be  described  in  any  brief  way.  But  by  the  aid  of  the  accom- 
panying diagrams  the  student  can,  afte/ some  study  of  ordinary 
descriptive  anatomy,  get  an  idea  of  the  architecture  of  these 
parts.  It  is  best  to  begin  from  below  with  the  spinal  cord,  and 
show  first  the  relations  of  its  different  columns  to  the  medulla 
and  pons  varolii. 

In  Fig.  156  it  will  be  seen  that  only  the  anterior  and  lateral 
fundamental  columns  of  the  cord  are  connected  with  the  gray 
matter  of  the  medulla  and  pons.  The  motor  and  sensory  tracts 
pass  through  it  uninterrupted.  The  antero-lateral  fundamental 
columns  connect  with  various  deposits  of  gray  matter  in  the  me- 
dulla and  pons  which  are  called  nodal  nuclei.  These  in  turn  are 
connected  with  the  cerebellum  and  pyramidal  and  sensory  tracts- 
There  is  a  long  band  of  fibres  in  the  medulla  and  pons  called  the 


308 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


Dosterior  lono-itudinal  bundle.  It  is  an  analogue  of  the  anterior 
fundamental  column  of  the  cord  and  connects  the  cranial  nuclei. 
It  is  connected  above  with  the  basal  ganglia. 

Flo-  157  shows  the  relations  of  the  spinal  cord  to  the  cerebruni 
and  c^rebelhim.  The  pvramidal  tracts,  having  mostly  crossed  m 
the  lower  medulla,  go  straight  up  through  the  internal  capsule  lo 
the  motor  area  of  the  cortex. 


Fig.  157.— Connections  op  Spinal  Cord  with  Cerebrum  and  Cerebellum. 
Motor  tracts  go  straight  to  cerebral  cortex.  Posterc-iuternal  and  part  of  postero- 
external I, sensory)  tracts  go  to  their  nuclei,  then  to  the  cei-ebellum  in  part,  to  optic 
thalamus  vand  corpora  quadrigemina  ?)  and  lenticular  nucleus  and  cerebral  cortex. 
The  antero-lateral  ascending  tracts  go  i-iaformatio  reticularis  to  optic  thalamus  and 
cortex.  The  direct  cerebellar  tract  to  vermis  and  then  rut  anterior  cerebral  peduncle 
to  opposite  red  nucleus  and  thalamus.  The  anterior  fundamental  and  lateral  funda- 
mental columns  to  pons  and  nodal  nuclei  and  to  cerebellum 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN. 


309 


The  sensory  tracts  cross  in  part,  while  part  have  crossed  al- 
ready in  the  cord.  They  ^o  up,  forming  the  inter-ohvary  tract, 
then  the  lemniscus  or  fillet.  In  part  then  they  enter  the  dorsal 
portion  or  tegmentum  of  the  cerebral  peduncle,  pass  through  the 
posterior  part  of  the  internal  capsule  to  the  motor  area  of  the 
cortex  and  parietal  lobe.  Some  fibres  enter  first  the  basal  ganglia. 
The  cord  is  connected  with  the  cerebellum  by  the  direct  cere- 
bellar tracts,  the  posterior  columns,  and  antero-lateral  funda- 
mental columns.  All  these  columns  carry  afferent  impulses  ex- 
cept those  of  the  antero-lateral  tracts,  which  are  made  up  of  asso- 
ciative fibres. 


Fig.  158.— Connections  of  Medulla-Pons- Cerebellum  with  Higher  Parts. 
Nuclei  of  columns  of  Goll  and  Burdach  with  optic  thalamus,  lenticular  nuclei,  and 
cerebral  cortex.  Olivary  body,  with  lenticular  nuclei  and  cortex.  Pons  nuclei  with 
frontal  and  occipito-temporal  cortex.  Cei-ebellum,  via  middle  peduncles,  to  pons 
nuclei  and  so  to  cerebrum.  Cerebellum,  via  anterior  cerebral  peduncles,  to  red 
nucleus,  optic  thalamus  (and  corpora  striata  and  brain  cortex?),  acusticus  and  tri- 
geminus, posterior  corpora  quadrigemina. 

In  general,  the  spinal  cord  is  connected  with  the  vermis  atid 
fibres  surrounding  the  dentate  nuclei,  the  pons  and  medulla  are 
connected  with  the  cortex  cerebelli  and  vermis,  while  the  ante- 
rior peduncles  arise  chiefly  from  the  dentate  nucleus.  (Marchi 
gives  other  relations.) 

The  connections  of  the  pons,  medulla,  and  cerebellum  are  shown 
in  Fig.  158.  The  olivarv  bodv  is  connected  with  the  cerebellum 
on  the  one  hand  and  to 'the  lenticular  nucleus  and  cortex  on  the 
other.  It  is  not  connected  with  the  cord.  Impulses  pass  from 
the  cerebellum  to  the  olives,  thence  up  to  the  bram.  JNuclei  in 
the  pons  are  connected  with  the  cortex  of  the  cerebellum  ana 
with  fibres  running  in  the  ventral  part  of  the  cerebral  peduncle 


310 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


on  either  side  of  the  pyramidal  tract,  to  the  frontal  and  temporal 
and  probably  occipital  lobes,  and  island  of  Reil.  The  nuclei  of 
the  acoustic,  glosso-pharyngeal,  and  vagus,  perhaps  other  sensory 
nerves,  are  connected  with  the  cerebellum  by  a  **  direct  sensory 
tract  ''which  goes  to  the  nuclei  of  the  cerebellum.  The  nodal 
nuclei  are  connected,  as  has  been  stated,  with  the  cerebellum. 

Fig.  159  shows  the  relations  of  the  optic  thalamus  and  cor- 
pora quadrigemina  to  other  parts.  The  corpora  quadrigemina, 
by  the  posterior  tuV^ercles,  are  connected  to  the  cerebellum  and 
8.coustic  nerve,  internal  geniculate  body  and  temporal  lobes; 
bv  the  anterior  tubercles  to  the  lemniscus  and  spinal  cord,  the 


Fig.  159.— Relations  of  Corpora  Quadrigemina  and  Optic  Thalamus  to  Other 
Parts.  OT,  Optic  thalamus  ;  CQ,  corpora  quadrigemina  ;  KN,  red  nucleus  :  S.  Luys 
body,  or  subthalamus  ;  SN,  substantia  nigra  ;  ON,  optic  nerve  ;  AX,  acoustic  nerve; 
L,  lemniscus;  SO,  superior  olive. 

optic  nerve  and  optic  thalamus,  external  geniculate  body  and 
occipital  lobes.  The  thalamus  is  connected  to  the  spinal  cord  by 
the  lemniscus,  to  the  medulla  and  cranial  nerves  by  the  posterior 
commissure,  to  the  optic  nerve  and  external  geniculate  body,  to 
the  cortex  of  the  frontal,  parietal,  occipital,  and  temporal  lobes, 
to  the  corpora  mamillaria  and  fornix,  and  to  the  subthalamus 
and  lenticular  nucleus.  All  its  connections  cannot  be  shown  or 
described;  but  it  is  the  most  richly  connected  ganglion  of  the 
brain. 

Fig.  IGO  shows  the  relations  of  the  corpus  striatum  to  the 
other  parts. 

It  is  connected  with  the  spinal  cord  by  the  lemniscus(?),  with 
the  red  nucleus,  subthalamus  and  thalamus,  with  the  substantia 


ANATOMY   AND   PHYSIOLOGY   OF  THE  BRAIN. 


;ii 


nigra,  pons  nuclei,  and  olives.  Its  connections  with  the  brain 
cortex  are  slight  and  those  with  the  motor  tract  doubtful.  The 
corpus  striatum  seems  to.  have  its  closest  relations  with  the  cere- 
bellum, partly  through  the  red  nucleus,  partly  through  the  nuclei 
of  the  pons. 

The  Membranes-  of  the  JB rain. —The  membranes  of  the  brain 
are  the  dura  mater,  the  arachnoid,  and  pia  mater.  The  dura 
mater  lines  the  inner  surface  of  the  skull.  It  is  attached  loosely 
to  the  concavity,  but  closely  to  the  base.  It  splits  into  two  layers 
to  form  the  venous  sinuses  of  the  skull.  The  inner  of  the  two 
layers  at  certain  points  projects  inward  to  form  membranous 


V7WM>W^W^^, 


Fig.  160.— Relations  op  the  Corpus  Striatum  to  Other  Parts. 


septa.  These  are  known  as  the  great  longitudinal  or  cerebral 
falx,  the  lesser  longitudinal  or  cerebeUar  falx,  and  the  tentorium. 
Hence  both  venous  sinuses  and  membranous  septa  are  formed 
out  of  the  inner  layer.  The  outer  layer  forms  the  periosteum  of 
the  bone.  The  dura  mater  is  supplied  with  sensory  nerves  chiefly 
by  the  trigeminus,  but  posteriorly  by  the  vagus.  The  blood  sup- 
ply will  be  described  later. 

The  arachnoid  is  a  thin,  transparent,  fibrous,  non- vascular 
membrane  lying  between  the  pia  and  dura  and  continuous  with 
the  spinal  arachnoid.  It  bridges  over  the  fissures  and  the  de- 
pressions at  the  base  of  the  brain  and  forms  between  the  pia  and 
itself  certain  lacunae  or  spaces.  These  are  the  central  lacuna 
found  at  the  beginning  of  the  fissure  of  Sylvius,  the  callosal  and 
those  of  the  transverse  fissures,  and  of  the  lateral  aspect  of  the 


312  DISEASES   OF  THE   NERVOUS   SYSTEM. 

l^ons  varolii.  The  space  betAveen  the  dura  and  arachnoid  is 
called  the  subdural  or  arachnoid  cavity.  It  is  lined  Avith  epithe- 
lium and  resembles  other  serous  cavities.  The  inner  surface  of 
the  arachnoid  is  connected  with  the  pia  by  numerous  delicate 
fibrous  x>rocesses.  The  space  between  these  membranes  is  called 
the  siiharachnoid  spcwe.  It  counnunicates  with  the  subdural 
space  by  means  of  the  foramen  of  Mag-endie,  which  lies  in  the 
part  of  the  arachnoid  that  passes  over  the  pons  and  medulla, 
closing  in  the  fourth  ventricle.  The  subdural  and  subarachnoid 
spaces  contain  a  serous  fluid.  The  normal  amount  ranges  from 
two  drachms  to  two  ounces,  it  being  greater  in  old  people.  The 
arachnoid  contains  no  nerves  or  blood- vessels.  It  is  described  by 
some  as  a  part  of  the  pia  mater. 

The  pia  mater  lies  beneath  the  arachnoid  and  is  closely  applied 
to  the  brain  in  all  its  folds.  It  is  continuous  Avith  the  spinal  pia. 
It  is  very  vascular  and  supplies  the  whole  periphery  and  part 
of  the  interior  of  tlie  brain  with  blood.  It  consists  of  two  layers : 
an  outer  holding  the  larger  vessels,  and  an  inner  delicate  layer 
closely  associated  with  the  superficial  neuroglia  of  the  brain. 
The  pia  mater  folds  upon  itself  and  passes  through  the  trans- 
verse fissure  into  the  third  and  lateral  ventricles  of  the  brain. 
These  vascular  folds  form  the  velum  interpositum.  which  gives 
off  a  choroid  plexus  to  the  lateral  and  third  ventricles.  Another 
fold,  the  inferior  choroid  plexus,  is  given  off  to  the  fourth  ventri- 
cle.    The  pia  mater  has  vasomotor,  but  no  sensory  nerves. 

Functions  of  the  Brain  JLemhrane. — The  dura  mater,  by  its 
outer  layer,  acts  as  a  perioste"um ;  by  its  inner  layer  as  a  lymph 
sac.  It  is  also,  by  virtue  of  its  sensitiveness,  a  protection  against 
injury  and  disease.  The  arachnoid  forms  the  inner  wall  of  the 
lymph  sac.  The  pia  mater  is  a  vascular  and  nutritive  organ.  It  is, 
however,  also  closely  connected  with  the  lymphatic  system  of  the 
arachnoid.  The  Ijlood  supply  and  lymph  supply  of  the  brain 
vary  in  amount.  In  congestion  the  lymph  can  pass  into  the 
spinal  canal  or  be  rapidly  taken  up  by  the  absorbents.  In  anaemia 
there  may  be  compensatory  increase  of  lymph.  This  fluid  in  dis- 
ease may  accumulate  in  the  arachnoid  sac,  the  subarachnoid 
space,  or  the  ventricles,  these  spaces  being  all  in  communication 
with  each  other. 

The  Blood  Supply  of  the  Braix  axd  its  Membraxes. 
—The  vascular  supply  of  the  scalp,  skull,  and  dura  mater  comes 
from  the  external  carotids;  that  of  the  eye,  brain,  and  pia  mater 
from  tlie  internal  carotids  and  vertebrals.  The  arrangement  is 
shown  here: 

f  Occipital,  inferior  meningeal,  arteries. 
Posterior  auricular. 

^  {  Ptjsterior. 

Ascending  pharyngeal,  posterior  meningeal. 
Internal  maxillary,  middle  meningeal,  small 
t         meningeal, 
f  Anterior  meningeal. 

*^  I  Posterior  communicating. 

[Anterior  choroid. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  BRAIN. 


313 


Vertebral  and 


f  \  Posterior  meningeal. 
I  Inferior  cerebellar. 


•  1         •         «?  -^  Anterior  cerebellar, 
basilar  give  off  ]  superior  cerebellar. 
[^  Posterior  cerebral. 

The  general  arrangement  and  distribution  of  the  arteries  of  the 
scalp  and  dura  is  shown  in  the  accompanying  diagram  (Fig.  161). 


Fig.  161.— Showing  the  Blood  Supply  of  the    Scalp  and   that  of  the  Dura 
Mater  by  the  Middle  Meningeal. 


The  Mood  supjDly  of  the  meninges  comes  from  the  anterior 
middle  and  posterior  meningeal  arteries.  These  all  come,  except 
the  small  anterior  meningeal  branches  and  a  small  posterior 
branch,  from  the  external  carotid.  The  blood  passes  into  the 
diploic  veins,  and  from  there  passes  chiefly  into  the  lower  occipi- 
tal and  lateral  sinuses.  Some  of  it,  however,  returns  in  the  vena? 
comites.  It  all  returns  down  toward  the  base  of  the  skull,  ihe 
most  important  of  the  arteries  is  the  middle  meningeal,  botii  on 
account  of  its  size  and  its  distribution  above  important  func- 
tional areas. 

The  blood  supply  to  the  pia  mater  and  brain  substance  comes 


3U 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


from  the  internal  carotid  and  the  vertebral  arteries.  The  branches 
of  the  former  artery  give  off  the  anterior  and  middle  cerebral,  the 
posterior  communicating:,  and  anterior  choroid.  The  vertebral 
arteries  give  off  the  inferior  cerebellar,  while  the  basilar  branch 
of  the  vertebrals  gives  off  the  transverse,  anterior  cerebellar, 
superior  cerebellar,  and  posterior  cerebral  arteries 


i    1 


—  It 


Fig.  1G2.— Showing  the  Arteries  at  the  Base  of  the  Brain.  Ou  the  right 
side  the  brain  is  cut  away,  showing  the  cerebral  arteries  and  the  course  of  the  pos- 
terior cerebral. 


The  cerebral  arteries,  anterior,  middle,  and  posterior,  are  the 
three  largest  and  most  important.  By  their  anastomoses  the 
circle  of  Willis  is  formed.  From  the  circle  of  Willis  and  the 
begmnings  of  the  three  arteries  mentioned,  several  groups  of 
vessels,  six  m  all,  are  given  oft".     They  enter  the  base  of  the  brain 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN. 


315 


and  supply  the  great  basal  ganglia  and  adjacent  white  matter. 
They  are  called  the  central  arteries,  and  they  are  the  vessels 
usually  affected  in  cerebral  hemorrhages  of  adult  life.  They  do 
not  anastomose  with  each  other.  The  cortical  arteries  are  the 
terminal  branches  of  the  great  cerebral  arteries.  They  anasto- 
mose with  each  other  but  slightly.  They  are  distributed  very 
widely  and  carry  much  more  blood  than  the  central  groups. 
Their  distribution  is  shown  in  Fig.  163.  The  cortical  arteries  are 
distributed  in  the  pia,  and  from  there  they  pass  in  two  sets,  a 
superficial  and  a  deep,  into  the  gray  matter,  and  for  a  short 
distance  into  the  white  matter.  They  pass  straight  in  at  right 
angles  to  the  surface.  They  have  richly  arborescent  branches 
which  do  not  anastomose ;  consequently  a  knife  plunged  straight 
into  the  brain  does  not  cut  many  vessels.     The  cortical  arteries 


Fig.  163.— Showing  the  Distribution  of  the  Artery  of  the  Sylvian  Fissure, 
A  Prolongation  of  the  Middle  Cerebral.  The  area  iii  front  of  the  shaded  part 
is  supplied  by  the  anterior  cerebral,  that  behind  by  the  posterior  cerebral. 


probably  anastomose  somewhat  with  each  other,  though  not 
very  freely.  There  is  slight  if  any  anastomosis  between  the 
cortical  and  central  arteries.  The  pressure  is  thought  to  be  less 
in  the  vessels  of  the  gray  matter. 

The  capillaries  are  surrounded  by  spaces  called  perivascular 
spaces  which  serve  as  lymj)hatic  channels.  The  neuroglia  cells 
send  processes  which  connect  with  or  form  passages  to  the  vessel 
walls  (Fig.  164). 

The  blood  of  the  convex  and  mesial  cerebral  surface,  flowing 
up  from  the  base,  leaves  the  capillaries  and  enters  veins.  Thence 
it  still  passes  upward,  and  for  the  most  part  enters  the  longitu- 
dinal sinus.  The  most  of  the  vessels  enter  the  posterior  portion  of 
the  sinus  and  in  a  direction  forward  and  upward,  i.e.,  agamst 
the  current  in  the  sinus.  The  course  of  the  blood  current  is, 
therefore,  opposed  both  to  gravitation  and  to  the  venous  flow. 


316 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  veins  of  the  cerebrum  are :  1,  the  superficial  cerebral ;  2.  the 
deep  cerebral  veins;  and,  3,  the  cerebral  sinuses.  The  superficial 
cerebral  veins  areven?e  comites.  Those  on  the  convex  and  mesial 
surfaces  empty  chiefly  into  the  superior  longitudinal  sinus,  as 
described ;  those  on  the  basal  surface  empty  into  the  cavernous 
and  lateral  sinuses.  These  veins  have  no  valves,  and  their  walls 
are  very  thin  and  without  muscular  fil^res.  The  deep  cerebral 
veins,  or  venae  (ialeni.  receive  the  blood  from  the  lateral  ventricles 
and  from  some  of  the  central  arteries  supplying  the  basal  ganglia. 
They  empty  into  the  straight  sinus. 

The  cerebral  sinuses  are  fifteen  in  number.  The  importailt 
ones  are  the  superior  and  inferior  longitudinal,  the  straight,  the 
lateral,  the  occipital,  the  cavernous,  and  the  superior  and  inferior 


Fig.  164.— Showing  the  Nei-roglia  Cells  of  the  Brain,  their  Relation  to  the 
Blood-Vessels  :  also  the  Sustentacular  Processes  of  the  Epithelial  Cells 
OF  THE  Lateral  Ventricle  (3Iarchi).  A,  Epithelial  cells  lining  lateral  ventricle  ; 
«,  process  of  same  ;  6,  spider  or  neuroglia  cell  ;  c.  blood-vessel. 


petrosal.  They  carry  blood  for  the  most  part  in  a  direction  from 
before  backward,  and  convey  it  eventually  to  the  internal  jugular. 

Most  of  the  blood  of  the  convexity  and  mesial  surface  must 
pass  into  the  longitudinal  sinus,  but  there  is  a  slight  connection 
of  some  of  the  veins  with  the  superior  ipetrosal  and  straight  si- 
nuses. The  superior  longitudinal  sinus  also  communicates  slightly 
with  veins  of  the  scalp  and  with  the  facial  vein.  Some  of  the 
blood  from  the  mesial  surface  also  goes  to  the  veins  of  Gralen. 

On  the  whole,  however,  the  system  of  the  convex  and  mesial 
cerebral  surface  is  a  close  corporation,  the  blood  having  to  pass 
into  the  superior  longitudinal  sinus  and  torcular  Herophili,  where 
it  meets  that  of  the  straight  and  occipital  sinuses,  and  flows  for- 
ward through  the  lateral  sinuses  to  the  internal  jugular.  The 
circulation  of  the  basal  surface  is  less  isolated.  All  the  basal  si- 
nuses communicate  with  each  other  freely,  and  there  are  slight 


ANATOMY   AND   PHYSIOLOGY  OF  THE   BRAIN.  317 

communications  between  the  veins  of  the  scalp  and  the  cavernous, 
lateral,  and  inferior  petrosal  sinuses.  It  is  safe  to  tie  anv  of  the 
sinuses,  except  the  lateral  and  the  posterior  part  of  the  longitu- 
dinal. The  cerebellar  veins,  superior,  inferior,  and  lateral,  empty 
into  the  straight,  the  lateral,  and  superior  petrosal  sinuses.  None 
of  the  cerebral  veins  or  sinuses  have  valves. 

The  pressure  in  the  internal  carotid  arteries  is  about  150  mm., 
that  in  the  cerebral  sinuses  TO  to  80  mm.  (Grerhardt),  and  that  in 
the  jugular  veins  is  almost  negative.  Both  arteries  and  veins  are 
more  delicate  than  the  extra-cerebral  vessels. 

Except  its  gray  matter,  the  brain  is  not  a  very  vascular  organ, 
but  this  gray  tissue  ranks  in  richness  of  blood  supply  with  the 
lungs  and  liver.  The  amount  of  blood  in  the  brain  at  any  one 
time  is  only  about  one  to  two  per  cent  of  the  total  blood  in  the 
circulation,  or  about  four  ounces  (Ranke). 

The  diameter  of  the  common  carotids  is  6.7  mm.  (Thorne),  that 
of  the  subclavians  6.2  mm.,  that  of  the  internal  carotids  4  mm., 
and  that  of  the  vertebrals  3.5  mm.  (Gerhardt).*  The  blood  to 
the  brain,  therefore,  has  passages  three-fifths  as  great  as  the  total 
arterial  area  near  the  heart,  and  the  blood  enters  these  passages 
at  a  pressure  (250  to  150)  three-fifths  as  great  as  that  in  the  ves- 
sels near  the  heart. 

The  Functions  of  the  Brain— Cerebral  Localization. 
— The  brain  is  the  seat  of  conscious  intelligence  and  mental  activ- 
ity. It  has  also  control  and  direction  of  voluntary  movements, 
it  is  the  seat  of  instinctive  acts,  and  it  regulates  in  a  measure  the 
vasomotor,  trophic,  and  secretory  mechanisms  of  the  body. 

The  Pra'frontal  Lohes. — The  prefrontal  lobes,  or  that  part 
of  the  brain  in  front  of  the  prsecentral  convolution,  are  concerned 
with  volition  and  the  j^ower  of  self-control,  concentration  of 
thought  and  attention.  The  posterior  i3art  contains  centres  for 
the  movements  of  the  head  and  eyes.  Injuries  in  this  part  of  the 
brain  produce  changes  of  character,  indicated  by  peevishness  and 
irritability  of  temper,  mental  enfeeblement,  lack  of  power  to  con- 
centrate the  mind  or  to  control  the  acts  or  emotions. 

The  Central  Convolutions,  Paracentral  and  Upper  Parietal 
Lobules. — This  part  of  the  brain  is  called  fhemotor  area,  because 
it  is  concerned  in  the  production  of  nervous  impulses  which  cause 
voluntary  motions  of  the  body.  Certain  parts  of  this  area  are  in 
relation  with  certain  groups  of  voluntary  muscles  on  the  oppo- 
site side  of  the  body.  These  areas  preside  not  so  much  over  sin- 
gle muscles  as  over  those  groups  of  muscles  which  act  together 
in  producing  definite  purposeful  acts.  The  lower  part  of  the 
central  convolutions,  known  as  the  central  operculum,  is  a  centre 
for  movements  of  the  larynx,  mouth,  tongue,  and  face.  Above 
this  area  and  about  the  middle  third  of  the  central  convolutions 
is  the  centre  for  the  movements  of  the  shoulder,  arm,  hand,  and 
fingers.    Still  farther  up,  near  the  longitudinal  fissure,  and  extend- 

*  J.  Crichton  Brown  gives  the  last  two  diameters  2.8  and  2.2  mm.  respectively. 


318 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


ing  over  into  the  mesial  surface  and  back  into  the  superior  parie- 
tal lobule,  is  the  area  for  the  trunk,  hips,  legs,  feet,  and  toes.  The 
base  of  the  first  and  second  frontal  convolutions  is  the  centre  for 
movements  of  the  head  and  eyes.  The  exact  arrangement  of 
these  centres,  which  have  been  determined  by  experiments  upon 
monkeys  and  other  lower  animals  as  well  as  by  chnical  and  sur- 
gical observations  on  man,  is  shown  in  the  accompanying  dia- 
grams. Probably  the  motor  area  is  also  the  centre  for  the  cuta- 
neous sensations  of  the  parts  corresponding  to  the  muscular 
groups  which  it  supplies,  so  that  what  is  called  the  motor  is  really 
a  sensori-motor  area.     The  motor  area,  when  irritated  by  disease, 


Fig.  1C5.— The  Cortical  Centres. 


l^roduces  paraesthesiae  and  convulsive  movements  in  the  groups 
of  muscles  which  it  represents.  Destruction  of  it  causes  not  only 
a  i^aralysis,  but  a  certain  amount  of  cutaneous  anaesthesia. 

The  various  sensori-motor  centres  are  not  sharply  limited,  but 
lap  one  over  the  other,  so  that  the  motor  area  for  the  forearm, 
for  example,  extends  over  somewhat  into  that  for  the  shoulder. 
The  corresponding  sensory  areas  are  still  more  diffuse,  so  that  it 
takes  a  much  more  extensive  destruction  of  a  certain  area  of  the 
motor  cortex  to  produce  an  anaesthesia  of  the  arm  than  it  does  to 
produce  a  paralysis  of  the  arm  (Figs.  165,  166). 

Bilateral  Representation. — Those  muscles  of  the  two  sides  of 
the  body  which  act  together  have  a  double  representation  in  the 
brain.     For  example,  each  group  of  muscles  used  in  inspiration 


ANATOMY  AND  PHYSIOLOGY  OF  THE  BRAIN. 


319 


has  a  centre  in  both  hemispheres;  consequently,  when  one  centre 
is  destroyed  no  paralysis  results,  for  the  reason  that  the  other 
centre  continues  its  work.  In  the  same  way  some  of  the  muscles 
of  the  face,  such  as  those  for  closing  tiie  eyes,  have  a  double  rep- 
resentation, and  a  lesion  destroying  the  centre  for  the  orbicularis 
IDalpebrarum  on  one  side  will  not  usually  cause  paralysis,  because 
of  the  continued  action  of  the  centre  of  the  other  side.  The 
more  perfect  and  habitual  the  associated  action  of  the  muscles  of 
the  two  sides  of  the  body,  the  more  completely  can  one  centre 
do  the  work  of  its  associate.  The  best  examples  of  the  mus- 
cles having  the  double  representation  are  the  orbicularis  palpe- 
brarum, the  muscles  of  the  vocal  cords,  the  muscles  concerned  in 


Fig.  1G6.— The  Cortical  Centres. 

deglutition  and  in  respiration.  The  muscles  of  the  viscera  and 
blood-vessels  have  no  known  representation  in  the  cortex  of  the 
human  brain. 

The  special  sensations  have  a  bilateral  representation  also; 
but  the  more  specialized  the  sense,  the  less  can  one  hemisphere 
take  the  place  of  the  other. 

Occipital  Parietal,  and  Temporal  Lobes— Centres  of  Special 
Sense.— The  special  senses  have  two  centres— the  primary  and  the 
secondary.  The  primary  centres  are  connected  with  the  ganglia 
at  the  base  of  the  brain ;  the  secondary  centres  are  situated  in 
the  cortex. 

The  primary  centre' for  vision  is  in  the  posterior  part  of  the 
optic  thalamus,  the  external  geniculate  body,  and  anterior  cor- 
pora quadrigemina.  The  secondary  centre  is  situated  in  the 
occipital  lobe,  and  particularly  upon  its  mesial  surface  and  in 
that  part  known  as  the  cuneus.     Each  occipital  lobe  is  the  centre 


320  DISEASES   OF  THE   NERVOUS   SYSTEM. 

for  visual  impulses  from  the  corresponding  half  of  the  retina  of 
each  eye;  for  example,  the  left  occipital  lobe  is  the  centre  for 
vision  of  the  left  half  of  the  retina  of  each  eye.  This  relation  is 
shown  in  the  diagram  (see  Optic  ^'erve).  Total  destruction  of  both 
occipital  lobes,  or  even  of  a  considerable  part  of  them  if  the  de- 
struction involves  the  median  surface,  will  cause  blindness.  De- 
struction of  one  lobe  causes  only  half-blindness  or  hemianopsia. 

T\\e  primary  centre  for  hearing  is  in  the  posterior  tubercle  of 
the  corpora  quadrigemina  and  the  internal  geniculate  body.  The 
secondary  centre  is  in  the  cortex  of  the  first  and  second  convo- 
lutions of  the  temporal  lobe.  Destruction  of  one  temporal  lobe 
causes  deafness  in  the  opposite  ear.  This  deafness,  however,  is 
not  complete  because  the  sense  of  hearing  has  a  bilateral  repre- 
sentation ;  each  ear,  in  other  words,  sends  fibres  to  the  temporal 
lobes  of  each  side,  although  more  fibres  cross  over  than  go  to 
the  lobe  of  the  corresponding  side.  The  consequence  is  that  the 
loss  of  one  temporal  lobe  is  in  a  measure  supplied  by  the  other 
{vide  Aphasia). 

The  primary  centre  for  smell  is  in  the  olfactory  lobes.  The 
secondary  centre  is  probably  in  the  uncus  and  in  part  of  the 
hippocamrjal  convolution.  Whether  the  tracts  for  the  sense  of 
smell  are  connected  with  the. optic  thalamus  or  other  ganglia  is 
not  definitely  known. 

The  primary  centre  for  taste  is  not  known,  but  sensations  of 
taste  may  connect  with  the  optic  thalamus  before  passing  into 
the  secondary  centre,  which  is  in  the  hippocampal  convolution. 

Centres  for  Jlemories. — There  are  certain  classes  of  sensations 
and  perceptions,  simple  in  character  and  frequently  repeated,  so 
that  they  finally  get  to  be  used  almost  automatically  in  their 
work.  These  impressions  relate  to  the  use  of  the  muscles  in 
speech,  in  writing,  and  in  gesture  language,  also  to  other  fre- 
quently repeated  purposeful  movements  of  the  limbs.  The  mus- 
cular movements  in  writing  and  speaking  are  so  often  repeated 
that  certain  areas  in  the  cortex  are  set  apart  for  the  memories  of 
these  processes.  The  visual  sensations  and  ideas  elaborated  from 
them,  which  are  frequently  repeated  in  learning  to  read,  have  also 
a  centre  Avhich  is  set  apart  for  them.  This  forms  a  centre  for  the 
visual  memories  of  language.  In  the  same  way  there  are  audi- 
tory sensations  and  ideas  elaborated  and  so  frequently  repeated 
as  to  be  used  automatically  in  acquiring  language.  These  are 
stored  up  as  auditory  memories.  We  have  what  may  be  called 
motor  memories  connected  with  speech  and  gesture.  These  spe- 
cial memories  have  been  found  to  have  a  certain  localization  in 
the  brain.  The  centre  for  the  memories  of  the  articular  move- 
ments of  speech  is  in  the  posterior  part  of  the  third  left  frontal 
convolution ;  the  centre  for  the  memories  of  the  movements  of 


ANATOMY  AND  PHYSIOLOGY  OF  THE  BRAIN.         321 

writing  is  not  perfectly  well  known,  but  is  thought  to  be  at  the 
posterior  i^art  of  the  second  left  frontal  convolution.  The  centre 
for  the  memories  of  gesture  language  is  unknown.  The  centre 
for  the  memories  of  ordinary  co-ordinate  movements  is  perhaps 
in  the  inferior  parietal  lobule.  The  centre  for  the  visual  mem- 
ories of  written  language  is  in  the  angular  gyrus,  extending  back- 
ward from  there  into  the  occipital  lobe.  The  centre  for  the  audi- 
tory memories  of  spoken  language  is  in  the  posterior  part  of  the 
first  and  the  corresponding  upper  part  of  the  second  temporal 
convolution.  In  right-handed  people  all  the  memory  centres  are 
in  the  left  cerebral  hemisphere ;  in  left-handed  people  they  are  in 
the  right  hemisphere.  The  destruction  of  these  memory  centres 
produces  different  forms  of  aphasia,  as  will  be  described  later. 
In  addition  to  that,  disturbances  in  these  centres  are  produced 
by  lesions  which  cut  off  the  associating  fibres  connecting  these 
centres  with  each  other  or  with  motor  or  sensory  centres  proper. 

The  Centrum  Ovale,  Corpus  Callosum,  and  the  Associative 
Functions  of  the  Brain. — The  different  parts  and  centres  of  the 
brain  are  connected  together  by  the  associating  tracts  and  with 
lower  lev^els  by  the  projection  fibres.  The  simpler  and  less  devel- 
oped centres  of  the  two  halves  of  the  brain  are  closely  connected 
by  fibres  that  run  chiefly  in  the  corpus  callosum.  The  more 
highly  specialized  and  less  simple  in  function  a  centre,  the  less 
close  is  its  coumiissural  connection  and  the  more  independent  is 
one-half  of  the  brain  from  the  other.  Thus  the  centres  for  the 
movements  of  the  thorax  in  respiration  are  closely  bound  with 
each  other ;  those  for  the  purposeful  movements  of  the  hands  less 
so ;  those  for  receiving  visual  impressions  are  almost  independent ; 
and  the  centres  for  the  memories,  which  are  still  more  highly 
specialized,  are  practically  entirely  independent.  We  infer  that 
the  higher  mental  functions,  therefore,  work  either  in  one  cere- 
bral hemisphere  or  in  the  other,  and  that  the  two  halves  of  the 
brain  do  not  co-operate  with  each  other  in  much  of  the  higher 
intellectual  work. 

The  corpus  callosum  is  the  great  commissural  tract  connect- 
ing the  two  cerebral  hemispheres  and  their  respective  centres. 
The  anterior  commissure  does  some  of  the  same  work,  being 
more  specially  connected  with  the  function  of  olfaction.  The 
posterior  commissure  has  comparatively  few  bilateral  connecting 
fibres,  its  function  being  more  to  connect  the  thalamus  with  the 
cranial  nerve  nuclei  and  other  centres  below. 

The  Corpus  Striatum.— This  ganglion  is  in  close  relation  with 
the  cerebellum  and  with  nuclei  in  the  pons.  It  is  also  in  connec- 
tion with  fibres  that  come  up  from  the  muscle-sense  tract,  in  the 
spinal  cord.  Its  functions  are  therefore  probably  connected 
with  securing  co-ordinate  and  purposeful  movements.    Destruc- 


322  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tion,  however,  of  this  ganghon  in  the  human  brain  produces  no 
definite  symptoms,  and  local  lesions  of  it  cannot  be  diagnosti- 
cated.    It  is  therefore  called  clinically  a  latent  region. 

The  Thalamus  Opticus. — The  thalamus  is  in  relation  by  its 
projection  fibres  Avith  the  frontal,  parietal,  occipital,  and  tem- 
poral cortex.  The  fibres  that  go  to  the  occipital  cortex  are  con- 
nected with  the  optic  tract,  and  have  to  do  with  the  function  of 
vision.  The  fibres  that  go  to  the  temporal  lobe  are  connected 
with  the  auditory  tract,  and  have  to  do  with  the  function  of  hear- 
ing. The  optic  thalami  seem  to  have  some  relation  to  the  ex- 
pression of  emotions.  In  cerebral  paralyses  in  which  they  are 
involved,  the  patient  cannot  involuntarily  express  joy,  grief,  etc. 
Lesions  of  the  posterior  jDart  of  the  thalamus  will  produce  par- 
tial blindness.  Other  than  this,  lesions  of  the  optic  thalamus 
produce  no  definite  symptoms  which  enable  us  to  make  a  local 
diagnosis.  Disturbances  of  hearing  have  not  certainly  been 
traced  to  lesions  in  the  thalamus.  It  is  thought  to  be  a  primary 
centre  for  sensations  of  touch,  muscular  sense,  and  perhaps  for 
smell  and  taste,  but  no  definite  facts  in  human  pathology  have 
as  yet  satisfactorily  proved  this.  Lesions  of  the  thalamus  sonie- 
times  produce  various  forms  of  mobile  spasm,  but  these  are  gen- 
erally attributed  to  irritation  of  the  fibres  of  the  internal  capsule, 
which  go  close  to  it.  Hence,  aside  from  disturbances  of  vision, 
the  optic  thalamus  also  must  be  considered  clinically  a  latent 
region. 

The  Corpora  Quadrigemina. — The  anterior  tubercles  of  the 
corpora  quadrigemina,  together  with  the  external  geniculate 
bodies,  form  part  of  the  primary  centres  of  vision.  The  anterior 
tubercles,  however,  have  more  to  do  with  reflex  movements  of 
the  pupil  and  ciliary  muscles  than  with  the  actual  visual  func- 
tion. The  posterior  tubercles  of  the  corpora  quadrigemina  and 
the  internal  geniculate  body  are  thought  to  be  connected  with 
the  auditory  nerve.  They  also  appear  to  receive  some  fibres  from 
the  cerebellum ;  hence  their  injury  or  disease  j^roduces  some  dis- 
turbances in  equilibrium  and  possibly  in  hearing.  Owing  to  the 
fact  that  the  nuclei  of  the  third  nerves  and  the  red  nuclei  lie  be- 
neath the  corpora  quadrigemina,  lesions  of  these  latter  produce 
irritations  and  paralyses  of  the  third  nerve,  disturbances  in  equi- 
librium and  forced  movements.  Lesions  in  this  neighborhood 
sometimes  cause  somnolent  and  stuporous  states. 

The  red  iniclei  are  comiected  with  the  anterior  cerebellar 
peduncles  on  the  one  hand  and  with  the  lenticular  nucleus  and 
optic  thalamus  on  the  other,  and  are  concerned  in  securing  equi- 
librium and  the  adjustment  of  the  body  in  space. 

The  Cerehellum. — The  cerebellum  is  connected  with  the  pons, 
the  cerebrum,  and  sjDinal  cord.     It  sends  impulses  through  the 


ANATOMY  AND  PHYSIOLOGY  OF  THE  BRAIN. 


323 


middle  peduncles  to  the  gray  matter  in  the  pons,  and  thence 
down  into  the  antero-lateral  columns  of  the  cord.  It  sends  im- 
pulses to  the  olivary  bodies,  and  thence  up  to  the  great  ganglia  at 
the  base  of  the  brain,  and  finally  it  sends  impulses  through  the 
anterior  peduncles,  which  cross  over,  enter  the  red  nuclei,  and 
connect  with  the  thalamus,  corpora  striata,  and  perhaps  with  the 
cortex  of  the  parietal  lobe.  It  receives  impulses  from  the  cortex 
of  the  frontal,  parietal,  occipital,  and  temporal  lobes,  which  go 
down  into  the  pons,  connect  with  nuclei  there,  and  thence  pass 
up  into  its  hemispheres.  It  also  receives  impulses  from  the 
spinal  cord,  through  the  posterior  peduncles.  There  is  therefore 
a  nervous  circuit  between  the  cerebrum,  brain  axis,  and  cere- 
bellum :  impulses  pass  down  from  the  cerebral  cortex  to  the  pons, 
thence  to  the  cerebellum ;  and 
other  impulses  pass  up  from  the 
basal  cord  to  the  cerebellum. 
Having  received  these  impulses, 
it  discharges  chiefly  along  the 
anterior  peduncles  into  the  ba- 
sal ganglia,  which  act  as  its  end- 
organ  (Fig.  167).  The  cerebel- 
lar influences  directly  affect  the 
spinal  cord  but  little.  The  cere- 
bellum has  undoubtedly  power 
of  securing  purposeful  move- 
ments and  of  enabling  us  to 
keep  our  equilibrium  and 
maintain  our  relations  in 
space.  The  v^ermis  or  median 
lobe  is  the  part  which  in  man  is 
most  important  in  doing  this 
work.  Lesions  of  the  lateral  lobes  or  hemispheres  produce  few 
direct  symptoms,  and  they  are  called  latent  regions.  Injuries  of 
the  median  lobe,  however,  produce  disturbances  in  equilibrium, 
forced  movements,  and  a  jDeculiar  form  of  inco-ordination  in  gait 
which  is  known  as  cerebellar  ataxia.  Lesions  of  the  middle 
peduncles  produce  forced  movements  also,  the  forced  movements 
being  either  to\vard  or  aAvay  from  the  side  of  the  lesion,  accord- 
ing as  it  is  an  irritating  one  or  a  destructive  one. 

The  pons  varolii  contains  some  of  the  cranial  nerve  nuclei  and 
collections  of  nerve  cells  which  are  connected  with  fibres  from 
the  cerebral  cortex  on  the  one  hand  and  the  cerebellum  on  the 
other.  It  also  contains  the  long  tracts  of  nerve  fibres  that  pass 
from  the  cerebrum  down  through  into  the  medulla  and  spinal 
cord  and  transverse  tracts  of  fibres  which  connect  the  two  hemi- 
spheres of  the  cerebellum.     Lesions  in  it  cause  disturbances  in 


Fig.  167.— Showing  the  Relations  of 
THE  Cerebellum  to  its  End-Organs,  the 
Basal  Ganglia,  and  to  Other  Parts. 


324  DISEASES   OF   THE   NERVOUS   SYSTEM. 

function  of  the  cranial  nerves  and  of  the  motor,  sensory,  and 
commissural  tracts. 

The  medulla  oblongata  contains  centres  of  the  cranial  nerve 
puclei,  and  in  it  also  are  various  reflex  and  automatic  centres  con- 
trolling and  regulating  the  vasomotor  system,  respiratory  and 
cardiac  rhythm,  visceral  movements  and  secretion. 

The  olixary  bodies  are  connected  with  the  cerebellum  and 
basal  ganglia,  but  not  Avith  the  spinal  cord.  Imj^ulses  pass  to 
these  bodies  from  the  cerebellum,  thence  up  to  the  brain.  When 
injured,  disturbances  of  equilibrium  and  co-ordination  occur. 

The  Latent  Regions  of  the  Brain.— There  are  certain  parts  of 
the  cerebral  cortex  destruction  of  which  and  irritation  of  which 
produce  no  special  and  distinctive  phenomena  in  man.  These 
are  the  greater  part  of  the  temporal  lobe  of  the  right  side  and  a 
portion  of  the  temporal  lobe  on  the  left  side.  A  part  of  the  in- 
ferior parietal  lobule  also  may  be  regarded  as  a  latent  region. 
The  frontal  lobe  we  have  already  spoken  of  as  being  concerned 
with  certain  mental  functions,  but  lesions  here  often  i3roduce  no 
symptoms,  and  they  may  be  to  a  certain  extent  regarded  as 
latent.  The  corpora  striata,  optic  thalami,  portions  of  the  cen- 
trum ovale,  and  the  two  lateral  hemispheres  of  the  cerebellum 
are  latent  areas. 

Brain  Weight. — The  average  weight  of  the  male  brain  is 
1,358  gm. ;  that  of  the  female,  1,235  gm.  The  weight  varies  with 
age,  sex,  race,  and  intelligence,  and  with  a  number  of  other  factors. 
The  average  weight  of  the  brain  at  birth  is  327.8  gm. ;  the  brain 
grows  raf)idly  until  the  age  of  four,  then  more  slowly  until  the 
age  of  seven,  then  very  slowly  up  to  the  age  of  sixteen  to  twenty. 
At  about  the  age  of  forty-five  in  man  and  fifty  in  woman  it  begins 
to  lose  weight  slowly,  and  at  the  age  of  eighty  or  over  it  has  lost 
about  120  gm.  (4  oz.).  The  brain  of  man  weighs  absolutely  about 
nine  per  cent  more  than  that  of  woman.  Relatively  to  the  body 
weight,  the  brain  weight  of  man  is  about  2fc ;  that  of  woman  a  very 
little  less.     The  sexual  difference  is  extremely  small.* 

The  brain  weighs  more  in  the  civilized  races,  and  more  in  cer- 
tain of  the  civilized  races  than  others;  the  brains  of  English,  Ger- 
man, and  Scotch  weigh  more  than  those  of  French,  Italian,  and 
Russian.  Some  of  the  African  and  Australian  tribes  have  the 
smallest  brains,  the  average  negro  brain  weighing  1 ,250  gm.  When 
a  brain  weighs  less  than  1,130  gm.  in  man  or  990  gm.  in  Avoman,  it 
is  called  a  microcephalic  brain;  if  the  weight  is  above  1.490 gm.  in 
man  or  1,345  gm.  in  woman,  it  is  called  a  megalocephalic  brain. 

Brain  weight  has  a  certain  relation  to  intelligence,  which  is 
not,  however,  an  absolute  one.  Among  a  hundred  men  of  more 
than  average  intelligence,  the  percentage  of  large  brains  Avould  be 
about  25,  whereas  the  percentage  of  large  brains  among  persons 
of  ordinary  or  low  intelligence  would  be  not  more  than  4  or  5. 
In  estimating  the  importance  of  brain  weight,  one  must  consider 
the  height,  the  weight  or  volume  of  body,  muscular  mass,  and 

*  J.  C.  Brown  finds  that  after  making  all  allowances,  woman's  brain  weighs  about 
one  ounce  less  than  man's. 


ANATOMY  AND   PHYSIOLOGY   OF  THE   BRAIN.  325 

superficial  area;  these  are  called  the  somatic  factors.  The  fol- 
lowing formula  has  been  devised  by  Snell  for  estimating  the 
mental  power  of  different  animals: 

In  this  formula  P  represents  the  psychical  factor  or  the  amount 
of  intelligence,  H  the  brain  weight,  K  the  body  weight,  S  the 
somatic  factor.  The  somatic  factor  has  been  estimated  to  be  for 
mammals  about  0.666.  Applying  this  formula,  we  find  that,  ex- 
pressed relatively,  the  intelligence  of  man  equals  0.87;  woman, 
0.86;  the  ape,  0.42;  the  rabbit,  0.59;  the  birds,  from  0.167  to  0.09. 

The  relative  weight  of  different  parts  of  the  brain  is  about  as 
follows:  Frontal  lobes,  28^/;  parietal  lobes,  36^;  occipital,  10,'^; 
temporal,  13$:^;  lobus  caudicis  or  island  of  Eeil,  9,^;  pons,  1^%. 
The  cerebellum  weighs  about  one-eighth  as  much  as  the  cere- 
brum. The  proportion  of  the  gray  to  the  white  matter  in  adults 
is  60  to  40  (Vierordt). 

The  depth  of  the  primary  fissures  is  not  quite  an  inch  (20  to  23 
mm.). 

There  are  one  thousand  two  hundred  to  two  thousand  million 
cells  in  the  cerebrum,  and  about  ten  million  large  cells  in  the 
cerebellum  (Meynert). 

About  one  million  cells  to  a  square  centimetre  is  the  estimate 
of  Engel. 


Preserving  and  Cutting  the  Brain. 

The  brain  should  be  placed  in  a  gallon  of  a  2i-per-cent  solu- 
tion of  bichromate  of  potash.  This  must  be  changed  daily  for  a 
week,  then  twice  weekly  for  a  fortnight ;  then  it  should  remain 
in  the  solution  for  three  or  four  months,  a  few  crystals  of  thymol 
being  added.  After  about  three  months  place  the  brain  in  95^ 
alcohol.     In  a  few  days  it  will  be  ready  for  cutting. 

In  cutting  the  fresh  or  preserved  brain  for  the  purpose  of  lo- 
cating gross  lesions,  remove  the  pons,  medulla,  and  cerebellum, 
place  the  brain  on  its  base,  and  make  sections  in  accordance  with 
the  directions  (Fig.  168).  The  sectional  views  exposed  are  shown 
in  the  following  series  of  cuts,  which  are  based  upon  those  of 
Exner. 


326 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


ABC  D  B         F 


a 


Fig.  168.— Showing  the  Points  at  which  the  Sections  are  Made,  a,  6,  Hori- 
zontal line  from  base  of  frontal  to  base  of  occipital  lobe  ;  A,  vertical  section  through 
middle  of  third  frontal  convolution  :  B,  through  operculum,  o  ,'  C,  through  superior 
praecentral  and  lower  end  of  Rolandic  fissures  ;  D,  through  re  and  posterior  end  of 
Sylvian  fissure  ;  E,  through  angular  gyrus  and  anterior  occipital  fissure  ;  F.  through 
parieto-occipital  fissure.  B  should  be  about  half-way  between  A  and  C  ;  E  half-way 
between  D  and  F.     (See  Figs.  169-174.) 


Fig.  169.— Section  Through  Line  A,  Fig.  168. 


ANATOMY   AND   PHYSIOLOGY   OF  THE   BRAIN.          327 


Fig.  170.— Section  Through  Line  B,  Fig.  168. 


Fig.  171.— Section  Through  Line  C,  Fig.  168. 


328  DISEASES  OF  THE  NERVOUS   SYSTEM. 

D 


Fig.  17:2.— Section  Through  Line  D.  Fig.  168. 
E 


Fig.  173.— Section  Throvgh  Line  E,  Fig.  168. 
F 


Fig.  174.— Section  Through  Line  F.  Fig.  168. 


CHAPTER   XYII. 

DISEASES   OF   THE   BRAIN   AND   ITS   MEMBRANES. 

GrENERAL   SYMPTOMS. 

It  Tvill  add  to  the  intelligibility  of  descriptions  of  brain  dis- 
eases and  their  symptoms  if  one  first  makes  himself  familiar  with 
certain  general  symptoms  that  underlie  more  or  less  nearly  all 
organic  disorders  of  this  organ.  Symptoms  due  to  disease  of  the 
brain  may  be  placed  in  four  classes :  first,  general  symptoms  of 
brain  irritation;  second,  general  symi^toms  of  brain  pressure; 
third,  symptoms  of  focal  irritation  or  destruction ;  and,  last,  those 
due  directly  to  the  pathological  process  itself. 

The  symptoms  of  brain  irritation  are  headache,  vertigo,  vom- 
iting, photophobia,  mental  irritability,  insomnia,  jDeculiar  feel- 
ings of  fulness  and  pressure  about  the  head,  noises  in  the  ears  or 
in  the  head,  tenderness  about  the  scalp,  and  in  severe  cases  con- 
vulsive symptoms  and  delirium. 

The  symptoms  of  brain  com^^ression  are  headache,  vomiting, 
mental  hebetude  or  dulness,  perhaps  some  form  of  paralysis,  con- 
tracted pupils,  and  eventually  coma.  AVith  this  there  is  often 
constipation  and  retracted  abdomen. 

The  symptoms  of  brain  irritation  are  often,  perhaps  usually, 
associated  with  a  hypersemia.  The  symptoms  of  brain  compres- 
sion may  be  associated  with  anaemia  or  oedema,  and  often  in  states 
of  malnutrition,  where  the  brain  is  impoverished,  the  symptoms 
resemble  much  those  of  compression.  Pressure  symptoms  and 
irritative  symptoms  often  lap  one  into  the  other,  and  they  cannot 
always  be  sharply  distinguished. 

Focal  symptoms  depend  almost  entirely  upon  the  location  of 
the  particular  lesion.  If  it  is  in  a  motor  area,  focal  symptoms  of 
irritation  Avould  be  spasmodic  phenomena,  such  as  convulsions. 
If  the  lesion  were  destructive,  the  symptoms  would  be  those  of 
paralysis  or  anaesthesia. 

The  symptoms  due  directly  to  the  pathological  process  itself 
may  be  very  slight.  Thus  in  case  of  a  tumor  of  the  brain,  the 
symptoms  are  mainly  caused  by  pressure,  irritation,  and  local 
disturbance  of  certain  special  parts  of  the  brain.  In  suppuration, 
however,  the  process  itself  may  produce  general  symptoms  such 


030  DISEASES    '3F   THE   NERVOUS    SYSTEM. 

as  are  associated  usually  with  sepsis — chills,  irregular  fever,  men- 
tal hebetude,  jDrostration,  emaciation,  and  sweats. 

Among  the  symptoms  pjrodueed  by  focal  lesions  there  are  a 
few  which  deserve  some  preliminai-y  general  study  because  they 
may  be  caused  by  lesions  of  very  different  kinds  and  occur  conse- 
quently in  very  different  forms  of  diseases.  Those  symptoms 
which  we  wish  particulai'ly  to  study  here  are  hemi^Dlegia  and 
aphasia.  These  represent  the  tAvo  gi-eat  dominating  symptoms 
pertaining  on  the  one  hand  to  motor  disturbance  and  on  the 
other  hand  to  sensori-motor  disturbance. 

Hemiplegia. — Hemiplegia  is  a  paralysis  of  one-half  of  the  body, 
involving  the  side  opposite  the  lesion.  The  face,  arm,  and  leg  are 
usually  all  paralyzed;  the  arm  most,  the  leg  next,  the  face  least. 
Hemiplegia  may  be  either  acute  in  onset  or  slow  and  progres- 
sive. Acute  hemiplegia  is  the  result  usually  of  hemorrhages  and 
-oftenings  of  the  brain,  more  rarely  of  inflammations  and  inju- 
ries. Progressive  hemiplegia  begins  gradually,  as  its  name  im- 
phes,  and  slowly  increases  until  the  height  of  the  disease  is 
reached.  It  is  usually  caused  by  tumors  growing  in  one  side  of 
the  brain,  but  it  may  be  caused  by  a  slowly  developing  patch  of 
sclerosis,  which  sclerosis  may  be  in  turn  only  a  part  of  a  multiple 
sclerosLS.  Further  description  of  the  peculiarities  of  hemiplegia 
will  be  given  under  the  head  of  Special  Diseases  of  the  Brain. 

Aphasia. — Aphasia  is  a  disease  of  the  faculty  of  language ;  and 
it  has  a  number  of  varieties,  in  accordance  with  the  joarticular 
part  of  the  brain  involved  and  the  particular  portion  of  the 
mechanism  of  this  faculty  that  is  destroyed.  By  the  faculty  of 
language  we  include  the  processes  by  which  we  hear,  see,  and  at 
the  .same  time  appreciate  the  meaning  of  s\Tnbols.  It  includes 
also  the  faculty  of  expressing  to  others,  by  voice,  writing,  or  ges- 
ture, our  ideas.  It  has  therefore  a  receptive  side  and  an  emissive 
-ide.  We  may  have  lesions  in  the  brain  which  destroy  that  part 
of  the  language  faculty  concerned  in  our  power  of  seeing  and 
understanding  written  words  or  the  gesture  language.  In  read- 
ing understandingly  one  sees  certain  words ;  these  words  revive 
certain  visual  memories  connected  with  past  perceptions.  Thus 
one  sees  the  word  ''  book ; ''  this  suggests  to  him  past  memories  of 
form,  color,  tactile  and  other  sen.sations  associated  with  the  past 
jjerceptions  of  books.  There  is  a  certain  centre  in  the  brain  where 
these  visual  memories  for  letters  and  words  are  located.  When 
this  centre  is  destroyed  the  memories  are  destroyed,  and  the 
word  '"book"  or  any  other  written  word  conveys  no  meaning. 
The  patient  can  spell  out  the  letters,  he  can  see  the  letters,  but 
he  cannot  read  anymore  than  if  he  had  never  been  taught.  The 
condition  is  known  as  alexia  ovicord-hlindness.  Again,  a  person 
may  have  learned  to  associate  certain  gestures  with  definite  ideas, 


DISEASES   OF   THE   BRAIN   AND   ITS  MEMBRANES.      331 

as  the  motion  of  carrying  a  glass  to  the  mouth  with  that  of  drink- 
ing, or  the  motions  of  using  a  knife  and  fork  with  that  of  eating, 
or  the  motions  of  the  deaf-and-dumb  alphabet  with  certain 
words  and  ideas.  These  memories  of  gesture  language  are  located 
in  certain  regions ;  and  when  they  are  destroyed  the  patient  is  no 
longer  able  to  understand  gestures  or  the  sign  language.  This 
condition  is  known  as  apraxia.  Both  apraxia  and  alexia  are 
forms  of  aphasia  which  come  under  the  general  head  of  mind- 
hlindness.  A  person  hears  certain  words,  as.  for  example,  the  word 
"  knife."  This  conveys  to  him  a  certain  idea  of  the  form,  color,  and 
other  properties  associated  with  knife.  The  memories  associated 
with  the  auditory  perception  of  different  words  are  stored  up  in 
a  certain  locality  which  is  the  centre  for  auditory  memories. 
When  this  centre  is  destroyed  the  person  hears  spoken  words, 
but  they  convey  to  him  no  meaning.  All  that  it  said  to  him 
sounds  as  if  it  were  in  a  foreign  language :  he  hears,  but  he  does 
not  understand.  This  condition  is  known  as  word-deafness.  So 
much  for  the  receptive  or  sensory  side  of  language. 

In  communicating  our  ideas,  we  speak,  write,  and  make  ges- 
tures. In  speaking  we  make  use  of  the  organs  of  articulation, 
and  this  use  involves  the  fine  adjustment  of  a  delicate  muscular 
ajDparatus.  In  the  act  of  exj)ressing  ideas  we  have  to  bring  into 
play  the  memories  of  the  i^ast  muscular  movements  of  this  artic- 
ulatory  mechanism.  These  movements  were  learned  by  a  slow 
and  painful  i^rocess  during  infancy.  After  the  power  of  speech 
is  acquired,  the  mechanism  works  readily  and  almost  automat- 
ically because  we  only  have  to  send  a  stimulus  to  the  centre 
which  presides  over  the  stored-up  memories  of  the  impulses  to 
properly  innervate  the  mechanism  of  speech.  There  is,  there- 
fore, a  centre  for  the  memories  of  the  movements  of  articulation 
— a  centre  which  is  of  course  closely  connected  with  the  motor 
areas  that  directly  innervate  the  larynx,  pharynx,  and  oral  and 
facial  muscles.  When  a  lesion  destroys  this  centre  for  si^eech 
memories,  a  person  is  unable  to  reproduce  the  words  necessary 
for  expressing  an  idea;  for  example,  he  sees  a  knife,  he  knows 
what  it  is.  but  the  memory  of  the  motions  necessary  to  express 
the  word  "  knife  ""  is  gone.  To  him  it  seems  that  the  name  is  gone, 
and  that  is  the  common  way  of  expressing  it.  He  cannot  say  the 
word  ■'  knife."  The  patient  may  wish  to  exj^ress  the  idea  of  pain. 
He  feels  the  pain,  he  knows  that  he  has  pain,  but  he  cannot  re- 
vive those  motor  memories  which  are  concerned  in  expressing  the 
word  "  pain ; ''  he  cannot  tell,  therefore,  in  Avords  what  is  the  mat- 
ter with  him.  When  a  person  is  thus  troubled,  he  is  said  to  have 
a  form  of  motor  aphasia  for  which  the  particular  name  given  is 
aphemia.  In  the  same  way  there  is  a  centre  for  the  memories  of 
the  muscular  movements  concerned  in  writing ;  and  when  a  lesion 


332  DISEASES  OF  THE  NERVOUS  SYSTEM. 

destroys  this  centre  the  patient  is  unable  to  write,  though  he 
may  be  able  to  speak.  This  condition  is  called  agraphia.  Fi- 
nally there  is  a  centre,  less  well  defined,  for  the  memories  of  the 
movements  used  in  gesture  language,  and  when  this  is  destroyed 
the  person  is  unable  to  express  his  ideas  by  gesture  or  sign  lan- 
guage.    This  condition  is  known  as  amimia. 

To  resume  now,  Ave  have  the  following  divisions  of  aphasia: 

Sensory  Aphasia.  Motor  Aphasia. 

,r-    TIT    1  \  Alexia.  Aphemia. 

Mnid-blmdness.  \\^         .  k  .- 

(  Apraxia.  Agraphia. 

,^.    ,  T     .  ( Word-deafness.  Amimia. 

Mmd-deafness.   i  ^^     .     _      . 

(  Music-deafness. 

Parapliasia. 

There  is  also  a  form  of  aphasia  in  which  the  patient  misplaces 
words,  often  to  an  extent  that  makes  his  speech  somewhat  inco- 
herent. This  is  called  j^ciTajjhaaia,  and  is  due  to  lesions  which 
destroy  some  of  the  associative  fibre-tracts  connecting  the  special 
centres  for  language.  Practically  we  often  find  mixtures  of  motor 
and  sensory  aphasia,  or  we  have  a  motor  aphasia  with  paraphasia. 
Patients  may  also  lose  the  power  of  expressing  themselves  by 
ordinary  speech,  but  may  be  able  to  use  signs;  they  may  not  be 
able  to  write  voluntarily,  but  can  write  to  dictation ;  they  may 
not  be  able  to  read  directly,  but  can  do  so  when  they  trace  out 
the  letters  with  a  pen.  These  different  forms  are  due  to  lesions 
which  destroy  various  connecting  tracts  as  well  as  certain  of  the 
centres.  The  commonest  form  of  aphasia  is  the  motor  aphasia 
in  which  there  is  aphemia  and  agraphia;  that  is,  loss  of  power  to 
speak  and  write.  This  may  not  be  complete,  and  then  there  will 
be  with  the  motor  aphasia  some  paraphasia. 

In  examining  a  patient  who  has  ajDhasia  one  should  note  the 
following  points :  Whether  he  can  speak,  name  objects,  repeat 
words  after  you,  write  from  dictation,  copy;  whether  he  can 
sing  or  express  himself  by  gestures ;  whether  he  can  read,  spell, 
read  by  tracing  letters  with  the  pen,  read  words  that  he  has 
written  himself ;  whether  he  can  understand  spoken  language  or 
gesture  language;  whether  he  can  appreciate  the  nature  and  use 
of  objects.  At  the  same  time  he  should  also  be  tested  for  hemi- 
plegia, deafness  in  each  ear,  acuity  of  vision,  hemianopsia,  and 
hemiansesthesia. 

The  location  of  lesions  in  the  various  forms  of  aphasia  has 
been  made  out  with  considerable  definiteness.  The  lesion  in 
aphemia  is  in  the  posterior  part  of  the  third  left  frontal  convo- 
lution or  Broca's  convolution;  for  agraphia,  sometimes  in  the 
base  of  the  second  frontal  convolution,  sometimes  in  the  angular 
gyrus.     For  gesture  language  there  is  no  known  centre.     The 


DISEASES   OF  THE   BRAIN   AND   ITS  MEMBRANES.       333 

lesion  in  word-blindness  and  apraxia  is  in  the  angular  gyrus,  ex- 
tending back  into  the  occipital  convolution.  The  lesion  in  word- 
deafness  is  in  the  posterior  part  of  the  first  temporal  and  upper 
part  of  the  second  temporal  convolution.  In  right-handed  peo- 
ple the  lesions  are  always  on  the  left  side ;  in  left-handed  people 
on  the  right  side  (see  Fig.  165). 


Malformations  of  the  Brain  and  its  Envelopes. 

Congenital  malformations  of  the  brain  are  of  little  practical 
importance,  for  in  most  cases  the  monsters  cannot  live  and  in  all 


Fig.  175.— Acrania. 

cases  they  are  better  dead.     I  shall  simply  give  a  brief  enumera- 
tion of  the  important  forms. 

rAnencephal}^ 
Abnormalities  J  Porencephaly, 
of  the  brain,     j  Absences  or  malformations  of  parts,  e.g.,   Oy- 

[        ciopia. 

^^bnornmlitie.  |  ^/^f/^^^cele. 

?/«i^Si?.SL   1  Encephalocele. 

us  envelopes.   [  Hydi^ncephalocele. 

Anencephaly  is  always  present  with  acrania.  In  anencephaly 
the  cerebellum  and  part  of  the  basal  ganglia  may  be  present,  in 
such  case  the  child  can  live  a  short  time  (Fig.  175). 

Porencephaly  is  often  an  artificial  condition.  It  will  be  ae- 
scribed  later.  .  .      ,       „-«i^. 

In  cyclopia  there  is  an  undivided  anterior  cerebral  vesicle, 


334 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  orbits  form  a  continuous  cavity  with  a  single  rudimentary- 
eye  (Fig.  176)  .  „ 

In  acrania  there  is  usually  anencephaly. 

Meningocele  is  a  hernia  of  the  brain  membranes,  arachnoid 
and  dura  through  a  cleft  in  the  skull.     In  encephalocele  the 


J 


Fig.  176.— Cyclopia. 


brain  also  protrudes.  Both  these  forms  occur  usually  in  the 
occipital  region  and  almost  invariably  in  the  median  line.  In 
hydrencephalocele  there  is  a  sac  with  fluid  contents. 


Diseases  of  the  Membranes  of  the  Brain. 

The  diseases  to  be  considered  under  this  head  are  anaemia 
and  hypertemia,  inflammation  of  the  dui-a  mater  or  pachymenin- 
gitis, and  inflammation  of  the  pia  mater  or  leptomeningitis. 

Anaemia  axd  Hyperemia  of  the  Membraxes  of  the 
Brain. — Anaemia  of  the  membranes  of  the  brain  is  a  condition 
that  cannot  be  separated  from  anaemia  of  the  brain  substance, 
and  will  be  considered  in  connection  with  it.  Hyperaemia  of  the 
brain  membranes,  so  far  as  it  relates  to  hyperaemia  of  the  pia 
mater,  must  also  be  considered  in  connection  with  hyperaemia  of 
the  brain  tissue.  Dural  hyperaemia,  or  congestion  of  the  dura 
mater,  is  a  condition  which  occurs  as  the  result  of  injuries,  sun- 
stroke, and  of  certain  infective  poisons,  especially  that  of  syph- 
ilis.    The  symptoms  are  those  of  pachymeningitis  of  the  slight 


DISEASES   OF   THE   BRAIN   AND   ITS   MEMBRANES.       335 

grade,  and  will  be  described  under  that  head.  They  consist 
mainly  of  pain,  occasional  attacks  of  vertigo,  and  sensations  of 
fulness  about  the  head.  The  treatment  is  that  for  the  beginning 
stages  of  a  meningitis. 

IXFLAMMATIOX   OF    THE   DURA   MATER   OR    PACHYMEXIIS^GI- 

Tis  Exterxa.— It  has  been  the  custom  to  describe  two  forms  of 
pachymeningitis,  the  external  and  the  internal.  Internal  pachy- 
meningitis, or  heematoma  of  the  dura  mater,  is  properly  a  hemor- 
rhagic disorder  and  is  described  under  the  head  of  Dural  Hemor- 
rhages. A  true  inflammation  confined  to  the  internal  surface  of 
the  dura  alone  is  of  extremely  rare  occurrence. 

Pachymeningitis  externa  is  a  disease  that  involves,  at  first  at 
least,  the  outer  surface  of  the  dura,  and  is  usually  of  surgical 
origin  and  interest. 

Mlologi/.— Accidents,  injuries,  caries  of  the  i^etrous  bone  in 
mastoid  disease,  of  the  ethmoid  bone  in  ozsena,  necrosis,  syphilis, 
and  erysipelas  are  the  usual  causes. 

The  symptoms  are  local  headache,  fever,  delirium,  sometimes 
even  convulsions  and  paralysis.  In  the  severe  cases  the  disease 
has  usually  extended  and  involved  the  pia.  Pus  is  generally 
formed,  and  burrows  between  the  bone  and  dura.  The  disease  is 
recognized  mainly  by  the  discovery  of  the  local  cause. 

The  course  is  acute  or  subacute. 

The  treatment  is  a  surgical  one. 

IXFLAMMATIOX   OF  THE   PlA  MATER   OR  LePTOMEXIXGITIS. 

— Inflammation  of  the  pia  mater  has  the  following  types :  simple 
meningitis  due  to  some  infection,  epidemic  cerebro-spinal  men- 
ingitis due  to  a  specific  general  infection,  tubercular  meningitis, 
and  syphilitic  meningitis. 

All  these  forms  of  meningitis  may  be  either  acute  or  chronic; 
the  chronic  form  being  usually  simply  a  sequela  of  the  acute. 

Acute  Simple  Leptomexixgitis.—^^/oZo^?/.— Acute  lepto- 
meningitis is  always  due  to  an  infective  process  reaching  the  cer- 
ebral membranes  usually  directly  from  without,  but  sometimes 
through  the  blood.  The  so-called  oedematous  inflammation  of 
alcoholism  and  inanition  is  the  only  exception.  The  most  com- 
mon source  of  infection  is  disease  of  the  middle  ear  and  mastoid 
cells.  Disease  of  the  frontal  sinuses  and  upper  nasal  passages; 
operations  on  those  parts;  disease,  injuries,  and  fractures  of  the 
cranial  bones — are  also  common  causes.  Pneumonia  is  the  most 
frequent  infective  disease  in  which  the  pyogenic  organisms  are 
carried  by  the  blood.  After  this  come  pyaemia,  septicaemia,  vari- 
ola, scarlet  fever,  more  rarely  endocarditis,  empyema,  rheuma- 
tism, measles,  typhoid  fever,  and  mumps.  Occasionally  a  brain 
abscess  reaches  the  surface  and  sets  up  a  meningitis.  Insolation 
can  of  itself  not  cause  it.     The  disease  is  more  frequent  in  males, 


336  DISEASES   OF   THE   NERVOUS   SYSTEM. 

and  is  distributed  through  all  ages  of  life,  though  it  occurs 
oftener  in  the  young. 

Symptoms. — The  symptoms  in  the  various  types  differ  some- 
what, but  have  a  general  similarity.  They  are  to  be  broadly 
grouped  into  the  prodromal,  the  irritative,  the  dei)ressive,  and 
the  paralytic  stages. 

Prodromal  symptoms  are  shorter  and  less  marked  in  simple 
meningitis  than  in  tubercular.  The  x^atient  suffers  from  malaise, 
languor,  headache,  vertigo,  irritability,  loss  of  appetite,  and  vom- 
iting.    Of  these  symx)toms  headache  is  the  most  notable. 

In  the  second  stage  the  dominant  symptoms  are  headache, 
delirium,  rigidity  of  the  neck,  hypersesthesia  of  the  skin,  retrac- 
tion of  the  abdomen,  vomiting,  irregular  fever,  contracted  and 
often  unequal  x^upils,  sometimes  optic  neuritis  or  retinitis.  The 
headache  is  usually  i^ersistent,  with  exacerbations  of  great  in- 
tensity. Rather  early  in  this  disease  the  patient's  mind  begins  to 
wander ;  he  mutters  incoherently ;  he  may  have  periods  of  vio- 
lence alternating  with  stupor.  In  some  cases  there  is  a  continu- 
ous low-muttering  delirium.  Vomiting  also  occurs  early  and  is 
of  a  violent,  explosive  (projectile)  character.  This  symptom  is 
not  always  i:)resent.  The  head  is  bent  back  and  the  X3atient  can 
be  lifted  from  the  pillow  by  j^lacing  the  hand  under  the  occiput. 
There  is  sometimes  a  general  rigidity  which  resembles  catalepsy. 
Drawing  a  dull  jjoint  along  the  skin  causes  a  red  line  to  appear 
{tache  cerehrale).  Pinching  or  rubbing  the  skin  causes  much 
pain.  The  abdomen  falls  in  and  assumes  a  characteristic  "  boat- 
shape."  The  pupils  are  usually  contracted  and  uneven.  The 
eyes  are  intolerant  to  light.  Optic  neuritis  occurs  often  when 
the  inflammation  is  at  the  base ;  but  it  is  a  late  symptom.  Con- 
^Tilsions  and  local  paralyses  of  the  cranial  nerves,  causing  sight 
strabismus,  ptosis,  or  facial  palsy,  may  occur.  The  fever  is  irreg- 
ular in  course  and  not  high— 101°  to  103 \  The  pulse  is  usually 
irregular  or  rather  intermittent.  It  varies  greatly  in  frequency 
and  may  be  rather  slow — 50  to  70.  Respiration  is  rather  quick- 
ened and  sometimes  irregular.  The  bowels  are  consti^Dated ;  the 
urine  small  in  amount  and  sometimes  albuminous. 

In  the  paralytic  stage  the  patient  becomes  stupid  or  coma- 
tose ;  there  is  still  some  rigidity,  except  in  the  very  last  stages. 
The  abdomen  is  still  greatly  retracted,  the  pupils  may  now 
dilate,  the  skin  become  moist,  and  the  patient's  bowels  and  blad- 
der move  involuntarily.  Death  now  occurs  in  one  or  two  days 
as  a  rule. 

When  the  disease  is  mainly  on  the  convexity  of  the  hemi- 
spheres there  is  more  delirium,  convulsive  and  jDaralytic  trou- 
bles; when  confined  to  the  base  there  is  less  delirium,  while 
paralysis  of  cranial  nerves,  optic  neuritis,  vomiting,  and  retrac- 
tion of  the  head  are  commoner  or  more  prominent. 


DISEASES   OF   THE   BRAIN    AND   ITS   MEMBRANES.       337 

Course  and  Duration. — The  disease  may  begin  suddenly,  and 
the  patient  pass  at  once  into  the  comatose  state,  dying  in  a  few 
days.  Usually  the  i^rocess  lasts  one  or  two  weeks;  it  may  be 
prolonged  for  several  weeks. 

The  prognosis  is  very  grave,  but  it  is  less  serious  than  in  tuber- 
cular meningitis  and  more  serious  than  in  the  cerebro-spinal 
form. 

The  diagnosis  is  based  on  the  presence  of  an  exciting  cause, 
such  as  disease  of  the  ear  or  nose,  trauma,  infective  fevers,  and 
upon  the  presence  of  the  symptoms  given.  It  is  usually  easily 
recognized,  the  main  difficulty  being  to  distinguish  it  from  tuber- 
cular and  cerebro-spinal  meningitis. 

Fatliologij. — The  disease  is  a  fibro-purulent  or  purulent  in- 
flammation. It  involves  usually  the  base  more  than  the  con- 
vexity, but  the  reverse  may  happen.  The  ventricles  are  often 
involved  and  may  be  independently  inflamed.  There  are  de- 
scriptions, therefore,  of  simple  basilar  meningitis,  meningitis  of 
the  convexity,  and  ventricular  meningitis  or  ependymitis.  The 
inflammatory  deposits  are  most  conspicuous  along  the  course  of 
the  Sylvian  fissure  and  the  vessels  branching  from  it,  about  the 
optic  chiasm,  and  at  the  posterior  and  under  surface  of  the  cere- 
bellum and  the  sides  of  the  pons.  It  may  lie  only  in  the  sub- 
arachnoid cavity,  but  usually  the  arachnoid  and  sometimes  the 
dura  are  implicated.  There  is  increase  of  fluid  in  the  ventricles 
and  arachnoid  cavities,  and  this  fluid  may  be  turbid.  The  sur- 
face of  the  ventricles  may  show  an  inflammatory  process. 

The  micro-organisms  found  in  meningitis  are  the  pneumo- 
coccus,  streptococcus  pyogenes,  intracellular  diplococcus,  the 
l^neumo-bacillus,  and  a  bacillus  resembling  that  of  typhoid  fever. 
Still  others  have  been  described,  and  the  process  is  apparently 
a  mixed  infection,  though  the  pneumococcus  is  found  oftenest. 

Treatment. — Prophylaxis  is  the  most  important  measure,  as 
there  is  no  specific  treatment.  Chronic  disease  of  the  ear  and 
nasal  sinuses  should  be  attended  to,  and  injuries  of  the  skull 
treated  with  the  strictest  regard  to  antisepsis.  The  patient 
should  be  kept  quiet,  a  dose  of  calomel  given,  and  small  doses  of 
iodide  of  potassium  administered  at  frequent  intervals.  An  ice 
cap  may  be  appHed  to  the  head  and  hot  applications  to  the  feet. 
Hot  poultices  along  the  upper  spine  are  useful.  Opium  must  be 
given  for  the  pain,  if  needed;  and  antipyretics  or  phenacetin 
sometimes  answer,  in  a  measure.  The  internal  use  of  iodoform 
has  been  highly  recommended,  gr.  vi.  to  gr.  xij.  daily;  shaving 
the  head  and  rubbing  upon  it  an  ointment  containing  '^^%  iodo- 
form, then  covering  the  scalp  with  an  oiled-silk  cap,  is  a  treat- 
ment highly  spoken  of.  Surgical  intervention  is  sometimes  justi- 
fiable. 


338  DISEASES   OF  THE   NERVOUS   SYSTE^^ 

Epidemic  Cerebro-Spinal  Mexijs^gitis  (Spotted  Fever). 
—This  is  an  acute  infective  disorder  and  is  produced  by  a  special 
micro-organism.  It  lias  certain  peculiar  clinical  characteristics 
which  lead  us  to  describe  it  separately.  Anatomically  the  changes 
involve  the  spinal  membranes  as  well  as  the  cerebral. 

Etiology.— The  disease  most  frequently  attacks  children,  but  it 
may  occur  at  any  age.  Males  are  affected  rather  more  often  than 
females.  It  prevails  in  the  form  of  epidemics  which  affect  cold 
and  temperate  climates  especially,  and  which  travel  from  one 
part  of  the  country  to  another.  It  may  occur  sporadically.  It 
most  frequently  develops  during  the  winter  season,  and  attacks 
persons  who  are  living  in  crowded  houses,  tenements,  or  barracks. 
It  is  slightly  contagious.  One  attack  does  not  confer  an  immu- 
nity against  a  second. 

Symj^toms. — The  general  ajDpearance  of  a  person  attacked  with 
the  disease  is  that  of  one  who  has  been  poisoned  by  some  agent 
which  is  extremely  prostrating  to  the  whole  system  and  at  the 
same  time  one  which  has  a  specific  inflammatory  effect  upon  the 
meninges  of  the  brain  and  spinal  cord.  When  the  disease  is  rapid 
and  malignant,  the  patient  seems  to  die  of  an  acute  toxaemia  be- 
fore any  inflammatory  i3rocess  has  time  to  develop.  In  milder 
cases  and  those  of  longer  dui'ation  the  prostration  is  less,  and  the 
evidences  of  inflammation  of  the  meninges  then  develop  in  the 
typical  way.  The  disease  may  begin  with  prodromal*  symjitoms 
of  malaise,  discomfort,  pain  in  the  neck,  vomiting,  and  headache. 
As  it  develops,  the  headache,  accompanied  with  giddiness,  in- 
creases, pain  and  stiffness  in  the  neck  become  more  violent,  pains 
run  down  the  back  and  radiate  to  the  limbs ;  there  is  photophobia, 
and  dehrium  in  many  cases  is  marked.  The  skin  is  hyperses- 
thetic,  the  pulse  rises  to  120  or  higher,  the  temperature  varies 
very  much  and  is  usually  raised  to  103^  104%  or  even  more.  The 
bowels  are  generally  constipated.  In  most  cases  there  develop 
certain  skin  eruptions,  usually  in  the  form  of  purpuric  spots; 
herpes,  urticaria,  and  erythema  are  occasionally  seen.  These 
eruptions  vary  very  much  in  different  epidemics;  the  purpuric 
spots  are  the  most  important  from  a  diagnostic  point  of  view,  and 
have  given  to  the  disease  the  name  of  spotted  fever.  As  the  dis- 
ease progresses  the  symptoms  of  irritation  and  pain  give  way  to 
those  of  somnolence,  stuiDor,  and  paralysis.  Optic  neuritis,  acous-' 
tic  neuritis,  and  inflammation  of  other  cranial  nerves  take  place, 
and  paralyses  of  the  limbs  may  be  added. 

The  disease  may  run  a  short  and  malignant  course,  killing  the 
person  in  a  few  hours  or  one  or  two  days.  In  moderate  cases  it 
lasts  about  two  weeks.  A  large  number  of  different  varieties  of 
the  disease  are  described,  such  as  the  abortive  form,  fulminating 
form,  and  typhoid  form.     The  disorder  is  often  complicated  with 


DISEASES   OF   THE   BRAIN   AND   ITS   MEMBRANES.       339 

pneumonia  and  bronchitis,  less  often  with  inflammation  of  the 
joints  and  serous  membranes.  The  disease  often  leaves  very  seri- 
ous sequelae,  the  most  important  being  deafness  and  spinal  irrita- 
tion or  chronic  spinal  meningitis.  A  large  proportion  of  deaf- 
mutes  owe  their  affliction  to  this  disease. 

Patlioloyical  Anatomy.— In  the  very  acute  cases  the  post 
mortem  shows  nothing  but  the  evidence  of  very  severe  blood- 
poisoning.  In  the  milder  and  more  chronic  cases  an  inflamma- 
tion involving  the  pia  and  arachnoid  of  the  brain  and  cord  is 
found.  This  inflammation  is  fibrinous  or  fibro-purulent  in  char- 
acter, and  may  be  accompanied  with  the  exudation  of  a  good  deal 
of  inflammatory  material.  Bacteriological  researches  show  that 
this  disease  is  due  to  the  presence  of  a  specific  micro-organism 
which  is  apparently  very  much  like  that  which  causes  pneu- 
monia. 

The  diagnosis  is  based  upon  the  history  of  an  epidemic  of  the 
disease  being  present,  upon  the  presence  of  the  ordinary  symp- 
toms of  acute  cerebral  and  spinal  meningitis,  such  as  headache, 
delirium,  retraction  of  the  head,  the  sunken  abdomen,  hypertes- 
thesia  and  pains ;  finally,  the  presence  of  the  peculiar  purpuric 
spots  or  of  herpes  of  the  face  will  enable  one  to  make  a  positive 
diagnosis.  One  must  learn  to  distinguish  the  disease  from  typhus, 
tetanus,  uraemia,  pneumonia,  and  from  the  other  forms  of  men- 
ingitis, especially  the  tubercular.  The  diagnosis  is  often  made 
difficult  by  the  fact  that  cerebro-spinal  meningitis  may  occur  in 
a  sporadic  form,  and  it  is  well  known  that  after  a  community  has 
been  once  visited  with  an  epidemic,  these  sporadic  cases  are 
liable  to  crop  up  from  time  to  time  for  many  subsequent  years. 
The  sudden  onset  of  the  disease,  the  spinal  symptoms,  the  skin 
eruption,  the  absence  of  history  of  injury  or  of  evidence  of  tu- 
berculosis w^ill  usually  enable  one  to  recognize  the  disorder. 

The  prognosis  varies  much  with  the  epidemic,  but  the  disease 
is  always  a  serious  one.  The  mortality  ranges  from  twenty  to 
eighty  per  cent ;  it  is  worse  when  the  disease  comes  on  suddenly 
and  severely,  with  early  coma.  It  is  better  in  persons  over  the 
age  of  ten.  Cranial -nerve  complications  are  unfavorable,  in  that 
they  are  apt  to  leave  permanent  deafness.  Severe  spinal  com- 
plications are  apt  to  leave  their  mark  in  the  form  of  a  chronic 
meningeal  trouble.  • 

Treatme7it.— There  is  no  specific  remedy  for  the  disease,  and* 
the  ordinary  antiphlogistic  measures  such  as  mercury  and  iodides 
are  of  less  value  than  in  other  forms  of  nieningitis.  The  patient 
should  be  given  sustaining  food,  and  everything  possible  should 
be  done  to  counteract  the  depressing  effects  of  the  toxaemia. 
Opium  or  morphine  internally,  chloral,  digitalis,  quinine,  ben- 
zoate  of  sodium  and  salicylate  of  sodium,  and  alcohol  are  the 


340  DISEASES   OF   THE   NERVOUS   SYSTEM. 

drugs  which  have  been  specially  recommended.  Warm  baths, 
hot  moist  applications,  and  leeches  have  all  been  tried  with 
more  or  less  good  results. 

Tubercular  Mexixgitis  (x\cute  Hydrocephalus).— This 
is  a  form  of  meningitis  due  to  infection  with  the  bacillus  tuber- 
culosis. It  differs  pathologically  from  other  forms  in  the  charac- 
ter of  the  infective  organism ;  anatomically,  in  the  fact  that  the 
Inflammation  is  usually  and  chiefly  basilar  and  never  purely  pur- 
ulent; etiologically,  in  that  it  chiefly  affects  young  children;  and 
symptomatologically,  in  the  presence  of  prodroraata  and  a  more 
irregular  course. 

^^/oZor/^.— Tubercular  meningitis  occurs  chiefly  between  the 
ages  of  two  and  ten,  sometimes  in  infancy,  rarely  in  adult  life, 
very  rarely  after  the  age  of  fifty.  Males  are  rather  more  subject 
to  it.  A  hereditary  history  of  phthisis,  a  scrofulous  diathesis, 
bad  hygienic  surroundings,  and  the  presence  of  tuberculosis  else- 
where in  the  body  predispose  to  it.  Tuberculous  milk,  the  erup- 
tive fevers,  especially  measles,  blows  on  the  head,  and  great  emo- 
tional excitement  ajDpear  to  act  as  exciting  causes. 

Symptoms. — A  knowledge  of  the  prodromal  symptoms  is  espe- 
cially important.  These  are  paroxysmal  and  intensely  severe 
headaches  and  darting  pains  in  the  head,  vertigo,  loss  of  appe- 
tite, explosive  vomiting  without  nausea,  the  vomited  matter  being 
usually  colorless  and  watery,  constipation,  an  altered  disposition, 
and  irritability.  The  tache  cerehrale  or  cerebral  macule,  more 
rarely  ptosis  and  facial  paralysis,  may  appear  early.  The  pro- 
dromal stage  often  lasts,  with  remissions,  three  or  four  weeks. 
When  the  disease  sets  in  there  is  more  persistent  headache ;  vom- 
iting, fever,  and  the  other  symptoms  of  meningitis  already  de- 
scribed appear.  The  irritative  stage  gradually  passes  into  the 
paralytic  and  comatose.  Death  occurs  in  two  or  three  weeks. 
In  infants  the  disease  often  runs  a  very  obscure  course,  the  pa- 
tient show^ing  chiefly  symptoms  of  brain  compression. 

Pathological  Anatomy. — In  rapidly  fatal  cases,  with  severe 
symj)toms,  there  may  be  only  an  intense  congestion  of  the  brain 
with  numerous  miliary  tubercles  in  the  pia  mater  at  the  base  and 
over  the  convexity.  Here  we  must  assume  that  a  bacillary  toxine 
causes  the  symptoms.  In  most  cases  there  are  decided  deposits 
of  tubercles  at  the  base,  with  fibrinous  inflammatory  deposits 
about  the  optic  chiasm,  along  the  fissure  of  Sylvius,  at  the  sides  of 
the  pons  and  elsewhere.  Miliary  tubercles  are  seen  scattered 
over  the  convexit\^  and  in  the  choroid  plexus  and  ventricles. 
They  are  generally  found  in  the  spinal  membranes  also,  especially 
over  the  cauda  equina.  The  tubercles  lie  beneath  the  pia  sur- 
rounding the  small  vessels.  They  may  coalesce  into  large  tuber- 
cular nodules.     There  is  usually  an  increase  in  the  arachnoid 


DISEASES    OP   THE   BRAIN   AND   ITS   MEMBRANES.       S-il 

fluid,  and  in  most  cases  an  increase  in  the  ventricular  fluid.  Some- 
what rarely  there  is  very  ^reat  distention  of  the  ventricles  and 
compression  of  the  convolutions.  This  condition  used  to  be 
called  acute  hydrocephalus.  Small  spots  of  softening  may  be  seen 
from  obliteration  of  the  vessels  by  the  tubercles.  The  bacillus 
tuberculosis  is  found  in  the  tubercular  nodules. 

Diagnosis. — As  regards  the  form  of  the  disease,  this  is  based  on 
the  hereditary  history,  the  age,  the  existence  of  tuberculosis  of 
the  lungs  or  other  organs,  and  the  peculiar  prodromata  of  the 
disease.     Occasionally  tubercles  can  be  seen  on  the  choroid. 

Prognosis. — This  is  usually  absolutely  bad,  yet  post-mortem 
observation  of  cases  dying  with  practically  no  inflammatory 
change  makes  it  seem  possible  that  the  disease  might  be  checked, 
and  a  good  many  cases  are  reported  where  it  apparently  has 
been.  Some  of  these  are,  however,  probably  cases  of  hereditary 
syphilis. 

Treatment. — So  far  as  now  known,  this  is  not  different  from 
that  given  under  the  head  of  meningitis  elsewhere.  It  seems, 
however,  as  if  in  time  some  anti-toxine  may  be  discovered  which 
will  check  the  progress  of  the  poison  and  the  development  of  the 
tubercle ;  meanwhile  the  best  thing  to  do  is  to  give  small  doses  of 
iodide  of  potassium  at  frequent  intervals  and  use  symptomatic 
treatment. 

Chronic  Hydrocephalus. 

This  is  a  disease  mainly  of  infancy,  characterized  by  a  gradual 
enlargement  of  the  head,  with  mental  deficiency  and  symptoms 
of  brain  irritation  caused  by  an  accumulation  of  fluid  in  the 
ventricles  of  the  brain. 

The  old  term  "  acute  hydrocephalus  "  meant  an  acute  inflam- 
mation with  effusion,  but  the  name  is  not  needed  and  is  best 
dropped.  Chronic  hydrocephalus  is  not  an  inflammatory  j^ro- 
cess,  but  one  due  to  mechanical  causes  or  to  defects  in  structure 
or  nutrition.  The  fluid  always  accumulates  in  the  ventricles  of 
the  brain ;  hence  chronic  hydrocephalus  is  always  internal.  The 
so-called  external  forms  of  hydrocephalus  are  inflannuatory  or 
else  are  secondary  to  meningeal  hemorrhage  or  brain  atrophy. 
Chronic  hydrocei)halus  is  almost  always  a  disease  of  infancy  and 
is  generally  congenital.  It  may,  however,  be  acquired.  In  speak- 
ing of  chronic  hydrocephalus,  we  refer  to  the  chronic  internal 
congenital  disease. 

Etiology.— Your  out  of  five  cases  begin  at  birth  or  within  the 
first  six  months  of  life.  Syphilis  (J.  Lewis  Smith),  alcoholism, 
lead-poisoning  m  the  parents,  and  some  unknown  family  taint 
predispose  to  the  disease.  Poverty  and  poor  nutrition  and  rick- 
ets are  also  factors. 


342  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Symptoms.— T\\e  head  may  be  so  larg^e  at  birth  that  instru- 
mental help  is  needed.  More  often  the  parents  notice  a  gradual 
increase  in  the  size  of  the  child's  head,  beginning  soon  after  birth. 
The  forehead  bulges,  the  occiput  stands  out,  the  fontanel] es  and 
sutures  widen,  and  pressure  shows  evidence  of  fluctuation.  Mean- 
while the  face  does  not  grow^  much  and  the  result  is  to  give  a 
triangular  shape  to  the  head.  It  may  measure  twenty-four, 
twenty-seven  and  one-half  (Minot),  thirty-two  (Bright),  and  even 
forty-three  inches  (Klein)  in  diameter.  These  extreme  measure- 
ments are  reached  only  after  one  or  two  years.  With  this  abnor- 
mal growth  of  the  head,  mental  and  physical  symptoms  appear. 
The  infant  is  restless  and  irritable,  its  appetite  may  be  good,  but 
the  general  nutrition  is  poor  and  its  bodily  growth  is  retarded. 


Fig.  177.— Chronic  Hydrocephalus. 

The  mind  does  not  develop ;  usually  it  does  not  or  cannot  learn 
to  walk.  It  may  be  unable  to  support  the  weight  of  its  head. 
There  is  strabismus  and  sometimes  optic  atrophy.  The  pressure 
of  the  dropsy  thins  the  orbital  bones  and  forces  down  the  axis 
of  the  eyeballs  (see  Fig.  177).  Vomiting,  coma,  and  convulsions 
eventually  appear,  and  the  child  dies  of  exhaustion  or  some  in- 
tercurrent disease  in  two  or  three  years. 

In  some  cases  the  trouble  is  less  serious,  it  ceases  to  progress, 
the  bones  solidify,  and  the  child  grows  up  with  good  intelligence. 

Chronic  hydrocephalus  sometimes  develops  in  late  childhood 
and  in  adult  life.  It  is  then  due  to  some  tumor  or  inflammatory 
process  obstructing  the  vense  Galenae  and  the  aqueduct  of  Syl- 
vius. The  symptoms  are  chiefly  those  of  brain  pressure,  and  the 
disease  cannot  be  recognized  with  certainty. 

The  hydrocephalus  which  is  associated  with  the  brain  atrophy 


DISEASES   OF   THE   BRAIN   AND   ITS   MEMBRANES.       343 

of  insanity  and  old  age  or  with  general  dropsical  conditions  has 
no  kinship  with  the  process  we  are  now  describing. 

Pathology.— The  disease  is  due  to  the  gradual  accumulation 
of  a  serous  fluid  in  the  ventricles  of  the  brain.  The  cause  of  this 
is  an  inflammatory  or  developmental  obliteration  of  the  foramen 
of  Magendie  and  the  adjacent  lateral  foramena  of  Mierziejewski. 
This  prevents  the  escape  of  the  ventricular  fluid  into  the  general 
arachnoid  cavity.  Contributing  factors  are  congenital  or  ac- 
quired defect  in  the  absorbents  of  the  ventricles  and  a  rachitic 
and  easily  yielding  skull.  The  attempts  to  make  chronic  hydro- 
cephalus an  inflammation  are  failures,  though  there  is  at  times 
a  thickening  of  the  lining  membrane  of  the  ventricles.  The  lat- 
eral ventricles  are  principally  and  often  solely  affected,  and  these 
are  so  distended  as  to  press  out  their  cerebral  walls,  flattening 
the  convolutions,  and  turning  them  into  a  thin  shell  often  less 
than  a  quarter  of  an  inch  in  thickness.  Sometimes  only  one  lat- 
eral ventricle,  and  in  rare  cases  only  the  fourth  ventricle,  is 
affected  with  the  dropsy. 

The  diagnosis  has  to  be  made  from  rickets  and  an  acute  in- 
flammatory process.  In  rickets  the  head  is  square,  the  f  ontanelle 
does  not  bulge,  the  enlargement  is  less,  and  there  are  signs  of  the 
disease  in  the  bones  elsewhere. 

Prognosis. — The  congenital  cases  usually  die  in  a  few  months, 
or  at  least  before  the  third  year.  Those  developing  in  infancy 
may  live  for  four  to  six  years;  and  in  mild  cases  the  disease  ceases 
to  progress  and  a  fairly  healthy  adult  life  is  reached. 

Treatment. — A  great  many  measures  have  been  recommended, 
but  there  is  no  unanimity  about  any  one  of  them.  In  such  a 
state  of  therapeutics  it  is  safe  to  say  that  treatment  is  of  little 
use.  The  most  rational  measure  is  the  inunction  of  mercury 
and  the  administration  of  iodide  of  potassium  combined  with 
tonics.  Surgical  measures  such  as  tapping  the  ventricles  are 
irrational  and  need  not  be  discussed.  Quincke's  method  of  tap- 
ping the  spinal  canal  will  not  apply  in  these  cases.  Though  it  is  a 
practicable  measure  as  I  have  found  by  experiments  on  the 
cadaver.  Strapping  the  head  with  diachylon  plaster  is  recom- 
mended by  Trousseau  and  by  J.  Lewis  Smith. 


CHAPTER   XYIII. 

DISEASES   OF  THE  BRAIN. 

These  diseases,  like  those  of  other  parts  of  the  nervous  sys- 
tem, consist  of  malformations,  vascular  disturbances,  inflam- 
mations, softenings,  hemorrhages,  degenerations  and  scleroses, 
chronic  infections,  tumors,  and  functional  disorders. 

Cerebral  hyper.emia  is  a  condition  in  which  there  is  an 
excessive  amount  of  blood  in  the  cranial  cavity ;  it  may  be  acute 
or  chronic,  active  or  i^assive. 

Etiology. — In  the  description  which  is  to  follow  I  shall  refer 
only  to  those  conditions  of  hypercenua  of  the  brain  w^hich  are 
pathological.  It  is  a  well -recognized  fact  that  hypersemia  of  the 
brain  occurs  physiologically  under  excitement  and  over-activity 
of  the  heart  and  from  various  stimuli ;  l)ut  a  pathological  condi- 
tion of  acute  congestion  may  be  induced  by  sunstroke,  certain 
drugs  such  as  alcohol,  and  by  injuries;  also  by  mechanical  causes 
which  prevent  the  exit  of  the  blood  from  the  cranium.  An  acute 
congestion  also  occurs  in  mania  and  in  many  forms  of  fevers,  as 
well  as  in  the  initial  stage  of  meningitis.  A  chronic  cerebral  hy- 
persemia  may  be  induced  by  the  causes  already  mentioned  as 
bringing  on  acute  congestion.  The  prolonged  use  of  alcohol, 
prolonged  mental  excitement,  overwork,  and  worry  may  also 
lead  to  this  condition.  The  foregoing  causes  lead  to  what  is 
known  as  active  congestion,  in  which  the  blood  is  driven  in  excess 
into  the  brain  through  the  arteries.  A  passive  congestion  may 
exist  in  which  the  blood  is  prevented  from  leaving  the  brain  and 
is  kept  mainly  in  the  intra-cranial  veins.  The  causes  of  passive 
congestion  are  mainly  mechanical,  such  as  cardiac  disease  and 
mechanical  obstructions  about  the  neck  from  tight  clothes  and 
an  obstruction  to  the  flow  of  blood  from  the  lungs  by  playing  on 
wind  instruments. 

Symptoms. — A  great  deal  has  been  written  regarding  the  symp- 
tomatology of  cerebral  hyperemia,  but  many  of  the  statements 
made  are  nothing  but  guesswork.  Probably  the  main  symptoms 
produced  by  an  active  congestion  of  the  brain  are  a  sense  of  ful- 
ness and  pressure,  a  feeling  of  constriction  about  the  head,  some 
headache  which  may  be  vertical,  mental  excitement  or  irritabil- 
ity, confusion  of  ideas,  vertigo,  insonmia,  ringing  in  the  ears, 


DISEASES   OF  THE   BRAIN.  345 

and  pulsating  sounds  in  the  head.  These  symptoms  are  some- 
times increased  when  the  patient  lies  down,  and  are  generally 
increased  when  the  patient  bends  the  head  over  so  as  to  prevent 
the  return  flow  of  blood  from  the  brain.  It  is  impossible  to  diag- 
nosticate passive  hypersenda  from  active  through  the  symptoms 
alone,  but  probably  in  the  former  condition  the  disturbances 
and  symptoms  mentioned  are  less  marked;  in  other  words,  an 
active  hypersemia  produces  more  phenomena  than  passive.  In 
either  case  examinations  of  the  fundus  of  the  eye  and  of  the  tym- 
panum furnish  no  sure  criteria. 

Pathology.— Qev^hrtxl  hypersemia  used  to  be  regarded  as  nearly 
synonymous  with  cerebral  neurasthenia.  In  the  writer's  opinion, 
it  is  secondary  to  the  neurasthenic  state;  and  produced,  if  it  exists 
in  that  state,  by  the  impaired  vasomotor  innervation  which  is 
characteristic  of  neurasthenia.  It  is  not  wise,  therefore,  to  make 
the  diagnosis  of  cerebral  hyperaemia  often  as  the  primary  condi- 
tion. It  is  only  after  traumatisms  and  sunstroke  or  after  a  men- 
ingitis that  we  can  speak  of  the  cerebral  hypersemia  as  being  in  a 
certain  sense  the  primary  condition  to  be  treated.  The  state- 
ment made  by  some  writers  that  cerebral  hypersemia  underlies 
certain  conditions  of  acute  delirium,  of  aphasia,  of  paralysis,  and 
even  dementia  or  insanity  can  hardly  be  supported.  In  many  of 
the  cases  of  cerebral  hyperaemia  where  symptoms  are  produced, 
there  is  undoubtedly  a  condition  of  toxaemia  which  is  a  con- 
tributing factor  to  many  of  the  symptoms. 

Treatment. — The  specific  treatment  of  cerebral  hypersemia, 
when  indicated,  consists  in  giving  large  doses  of  fluid  extract  of 
ergot  and  bromide  of  potassium.  One  or  two  drachms  of  the 
ergot  three  times  a  day  and  fifteen  or  twenty  grains  of  bromide 
of  potassium  may  be  prescribed.  Wet  cups  to  the  back  of  the 
neck,  the  cautery  in  the  same  region,  ice  caps,  purgatives,  quiet 
and  rest,  and  a  careful  regulation  of  the  diet  and  the  bowels 
are  all  important  measures. 

Cerebral  Anemia.— This  condition,  like  hypersemia,  may 
be  either  acute  or  chronic. 

It  occurs  among  the  young  ;  more  often  in  females  than  in 
males.  It  is  seen  in  early  adult  life,  where  it  is  induced  by  the 
various  causes  producing  general  anaemia,  and  again  after  the 
climacteric,  when  it  is  due  to  organic  changes  in  the  cerebral 
arteries  of  the  nature  of  an  obliterating  endarteritis.  Bright's 
disease  and  syphilis,  exhausting  diseases  and  profuse  hemor- 
rhages, and  such  disorders  of  digestion  and  nutrition  as  lead  to 
general  anaemia  produce  also  cerebral  anaemia.  A  potent  cause 
of  acute  cerebral  anaemia  is  fright. 

Si/7nptoms.— The  symptoms  of  acute  cerebral  anaemia  are  ver- 
tigo, confusion  of  ideas,  nausea,  faintness  or  complete  syncope. 


346  DISEASES  OF  THE  NERVOUS  SYSTEM. 

In  chronic  cerebral  anaemia  the  symptoms  are  mental  apathy 
and  a  teeling  of  disinclination  to  work,  tendency  to  somnolence 
in  the  day-time  and  insomnia  at  nit^ht,  mental  depression,  head- 
aches which  are  usually  frontal  or  vertical,  occasionally  some 
vertigo  and  tinnitus.  There  may  be  spots  before  the  eyes  and 
undue  sensitiveness  to  sounds.  In  children  some  very  severe 
symptoms  are  attributed  to  cerebral  ansemia,  but  here,  as  in  hy- 
peremia, it  is  probable  that  there  are  other  causes  at  work,  par- 
ticularly toxic  agents  or  reflex  disturbances. 

Diagnosis. — A  chronic  anaemia  of  the  brain  can  hardly  be 
recognized  except  through  the  evidences  of  a  general  anaemia. 
When  this  is  present  and  there  are  also  symptoms  such  as  have 
been  described,  a  fairly  certain  diagnosis  can  be  made.  We  must 
look  upon  cerebral  anaemia  as  being  in  almost  all  cases  a  second- 
ary phenomenon,  except  in  the  aged,  and  then  the  trouble  is  due 
not  alone  to  poverty  of  the  blood,  but  to  the  fact  that  the  circu- 
latory apparatus  is  diseased.  It  is  generally  believed  that  in 
cerebral  anaemia  the  symptoms  somewhat  improve  by  the  hori- 
zontal position  and  are  made  w^orse  by  the  upright  position.  It 
is  also  asserted  that  in  anaemia  the  pupils  rather  tend  to  be 
dilated,  while  in  hyperaemia  they  are  contracted. 

Treatment. — Treatment  should  be  directed  toward  enriching 
the  supply  of  blood  and  toward  improving  the  general  nutrition. 
It  consists,  therefore,  in  the  administration  of  preparations  of 
iron  and  of  such  tonics  as  the  mineral  acids,  strychnine,  quinine, 
and  nitroglycerin. 

INFLAMMATION   OF   THE  BRAIN— ENCEPHALITIS. 

The  forms  of  inflammation  of  the  brain  are  acute  suppurative 
encephalitis,  acute  non-suppurative  encephalitis,  chronic  enceph- 
alitis, chronic  polioencephalitis.  Inflammations  of  the  brain  are 
analogous  to  those  of  the  spinal  cord ;  that  is  to  say,  there  are 
acute  suppurative  inflanniiations  or  abscesses,  and  acute  exuda- 
tive inflammations  with  or  Avithout  necrosis,  and  there  are  chronic 
inflannnations.  The  brain  differs  from  the  spinal  cord,  however, 
in  that  acute  suppurative  inflammation  is  comparatively  fre- 
quent, while  the  acute  exudative  inflammations  are  extremely 
rare.  Chronic  inflammation,  also,  of  the  brain  is  rarer  than 
chronic  inflammation  of  the  cord,  if  we  except  that  type  which 
underlies  general  paresis. 

Acute  Suppurative  Excephalitis  (Abscess  of  the  Braix). 

Brain  abscess  is  a  suppurative  inflammation  which  affects  the 
parenchymatous  and  other  structures  of  the  organ.  It  is  always 
a  focal  disease,  but  may  be  single  or  multiple. 


DISEASES   OF  THE  BRAIN.  34? 

Etiology.— ThQ  primary  cause  of  all  forms  of  brain  abscess  is 
a  microbic  infection.  The  form  of  microbe,  its  mode  of  entrance, 
and  the  part  of  the  brain  attacked  vary  greatly.  The  predis- 
posing causes  relate  chiefly  to  age  and  sex.  Brain  abscess  rarely 
occurs  before  the  first  year  or  after  the  fiftieth  year  of  life.  It  is 
rather  frequent  in  young  people,  and  occurs  on  the  whole  often- 
est  between  the  ages  of  ten  and  thirty.  Males  are  more  often 
affected  than  females  in  the  ratio  of  about  three  to  one.  The 
exciting  causes  are  chiefly  disease  of  the  ear  and  of  the  cranial 
bones,  injuries,  and  remote  suppurative  processes.  To  this  may 
be  added  infectious  fevers  and  the  presence  of  tumors.  Inflam- 
mation of  the  middle  and  internal  ear  is  the  most  common 
cause  of  brain  abscess.  The  disease  affects  the  tympanum  and 
mastoid  cells,  more  rarely  the  labyrinth.  It  is  usually  a  sup- 
purative process  of  long  standing.  Caries  of  the  ethmoid  and 
nasal  bones  and  of  the  orbital  cavity  leads  to  brain  abscesses  in  a 
considerable  proportion  of  cases.  After  chronic  ear  and  bone 
diseases,  injuries  are  the  most  frequent  cause.  The  injury  may 
be  a  compound  fracture  with  direct  infection  from  the  open 
wound,  or  the  abscess  may  be  the  result  of  contrecoup  and  may 
develop  in  a  part  of  the  brain  opposite  to  that  which  w^as  in- 
jured, or  the  abscess  may  develop  below  the  point  injured,  there 
being  apparently  healthy  tissue  between  the  surface  of  the  brain 
and  the  diseased  part.  These  abscesses  develop  through  lacera- 
tion of  brain  tissue  and  subsequent  infection  of  the  wound  with 
organisms.  The  most  common  remote  suppurative  processes 
which  are  followed  by  brain  abscess  are  tubercles,  inflammation 
of  the  lungs,  fetid  bronchitis,  and  empyema.  Brain  abscess  may 
develop,  however,  from  distant  points  of  suppuration  on  the  ex- 
tremities or  in  almost  any  part  of  the  body.  Pyaemia  may  lead 
to  the  production  of  brain  abscess.  Among  the  infectious  fevers 
which  are  complicated  with  brain  abscess  are  diphtheria,  typhoid 
and  typhus  fevers,  erysipelas,  small-pox,  the  "grippe."  The 
oidium  albicans  or  thrush  may  also  be  a  cause.  Brain  tumors 
sometimes  become  surrounded  by  a  suppurative  encephalitis  or 
may  break  down  with  the  formation  of  mixed  suppurative  and 
neoplastic  tissue.  Tubercular  tumors  are  most  frequently  accom- 
panied by  suppurative  encephalitis. 

Symptoms.— Br SLin  abscesses  take  sometimes  an  acute  and 
sometimes  a  chronic  course.  In  acute  cases  the  symptoms  de- 
velop rapidly  and  the  disease  runs  its  course  in  a  few  days  or 
w^eeks.  The  symptoms  come  under  the  general  head  of  those  of 
pressure,  those  of  poisoning  from  the  diseased  focus,  and  local 
symptoms  due  to  irritation  or  destruction  of  certain  special  areas 
of  the  brain.  The  pressure  symptoms  are  those  of  headache 
which  is  often  very  severe  and  persistent,  vomiting  which  is  quite 


348  DISEASES   OF   THE   NERVOUS   SYSTEM. 

frequent  though  not  invariable,  vertigo,  and  a  condition  of  men- 
tal dulness  wliich  may  pass  into  a  delirium,  ending  finally  in  coma. 
Optic  neuritis  often  occurs.  The  pupils  are  apt  to  be  irregular, 
but  furnish  no  definite  indications.  The  pulse  is  usually  slow, 
ranging  from  60  to  70,  but  it  varies  a  great  deal.  The  tempera- 
ture is  normal  or  subnormal  as  a  rule,  but  this  also  varies,  and  it 
may  rise  several  degrees  above  normal,  alwaj's  running  an  irregu- 
lar course.  The  toxic  symptoms  are  those  which  we  get  in  septic 
poisoning;  namely,  iDrostration,  irregular  fever,  emaciation,  ano- 
rexia, and  such  mental  and  sensory  disturbances  as  have  already 
been  referred  to.  As  a  result  of  local  irritation  or  destruction, 
there  occur  convulsions,  paralysis,  aphasia,  and  disorders  of  some 
of  the  special  senses.  Convulsions  are  not  very  common.  AVhen 
they  occur  they  are  generally  of  an  epileptic  character.  The 
paralysis  is  usually  in  the  form  of  hemiplegia.  The  cranial  nerves 
are  not  often  involved,  if  we  except  the  oi^tic.  The  urine  is  said 
to  show  a  diminution  in  chlorides  and  an  increase  in  phosphates. 
The  patient  dies  finally  in  coma  from  exhaustion. 

In  the  chronic  form  of  brain  abscess  the  symptoms  may  for 
weeks,  months,  or  years  remain  practically  latent,  after  the  ex- 
citing cause  has  been  at  work  and  after  the  abscess  has  been  es- 
tablished. The  patient  during  this  latent  stage  may  suffer  from 
headache,  vertigo,  mental  irritability,  and  depression ;  he  may  at 
times  have  a  convulsive  attack.  Occasionally  there  will  be  an 
exacerbation  of  the  disease,  at  which  time  he  suffers  from  intense 
pain,  vomiting,  perhaps  delirium  or  a  convulsion.  From  this  he 
recovers  and  continues  in  a  fairly  good  state  of  health  again. 
After  a  variable  period,  usually  of  weeks  or  months,  the  terminal 
stage  sets  in.  This  terminal  stage  of  the  chronic  form  may  as- 
sume very  much  the  characters  of  the  acute  form  already  de- 
scribed. In  other  cases  it  shows  itself  by  a  sudden  apoplectic  or 
epileptic  seizure  or  a  sudden  attack  of  coma,  in  which  the  patient 
sinks  and  rapidly  dies.  These  terminal  phenomena  are  due  to 
the  fact  that  the  abscess,  which  has  been  previously  encysted  and 
quiescent,  suddenly  breaks  into  a  lateral  ventricle  or  through  the 
surface  of  the  brain,  or  to  the  fact  that  a  hemorrhage  occurs  into 
the  abscess. 

Complications.— The  common  complications  of  brain  abscess 
are  a  phlebitis  of  the  superior  petrosal  and  lateral  sinuses  and  a 
meningitis.  The  phlebitis  accompanies  abscesses  that  are  caused 
by  disease  of  the  ear.  The  meningitis  may  be  caused  by  ear  dis- 
ease, but  more  frequently  accompanies  abscesses  due  to  injury. 
"When  phlebitis  is  present  there  will  be  found  an  oedema  about 
the  ear  and  neck  and  a  hardness  of  the  jugular  veins.  In  men- 
ingitis there  is  apt  to  be  more  rigidity  of  the  neck,  more  pain, 
and  there  are  often  cranial-nerve  paralyses. 


DISEASES   OF   THE   BRAIN.  349 

FatJiolog I/.— Acute  suppurative  encephalitis  resembles  acute 
suppurative  myelitis  in  the  intimate  nature  of  the  clianges  that 
take  place.  Tliere  is  an  intense  congestion  of  the  parts,  which 
give  it  a  reddened  appearance  and  Avhicli  used  to  give  to  this 
process  the  name  of  red  sjftening.  This  condition,  however,  is 
only  the  initial  stage  of  the  suppurative  inflammation  and  does 
not  deserve  to  be  ranked  as  a  sijecial  form  of  inflammatory  pro- 
cess. It  is  possible  that  in  some  cases  the  inflammation  may  get 
no  further  than  the  stage  of  red  softening.  The  congestion  then 
gradually  disappears,  absorption  of  exudate  occurs,  and  a  more 
or  less  complete  recovery  takes  place.  When  the  process  contin- 
ues, however,  the  parts  become  crowded  with  leucocytes  and 
infiltrated  Avith  inflammatory  exudate.  The  nerve  fibres  and 
cells  are  destroyed,  in  part  mechanically,  in  part  by  the  poison- 
ous influence  of  the  pyogenic  organisms.  The  nerve  cells  lose 
their  normal  contours,  swell  uid,  and  disintegrate ;  the  neuroglia 
cells  absorb  the  broken-down  detritus  and  swell  up,  forming 
what  are  known  as  granular  corpuscles ;  the  leucocytes  increase 
until  a  purulent  mass  is  formed.  The  total  result  is  a  mixture  of 
broken-down  nerve  fibres  and  cells,  leucocytes,  and  granular 
bodies.  Bacteriological  tests  show  the  presence  of  various  pyo- 
genic microbes.  The  abscess  thus  formed  v^aries  in  size  from  one 
to  six  or  eight  centimetres  in  diameter  (two-fifths  to  three  inches). 
It  is  generally  somewhat  round,  and  if  the  case  is  chronic  a 
fibrous  wall  is  formed.  It  takes  from  three  to  four  weeks  for  such 
a  wall  to  develop  (Fig.  178).  Brain  abscesses  are  usually  single, 
occasionally  there  are  two  or  three.  In  some  conditions  they  are 
multiple;  that  is  to  say,  there  may  be  fifteen,  twenty,  or  more. 
Multiple  brain  abscesses  are  always  small  and  are  usually  due  to 
pyaemic  infection. 

Location. — Brain  abscesses  involve  the  cerebrum  oftener  than 
the  cerebellum,  in  the  proportion  of  about  four  to  one  (Barr). 
Thej^  occur  rather  oftener  in  the  right  cerebrum.  They  are  very 
rare  in  the  pons  and  medulla.  The  cerebral  lobes  oftenest  affected 
are  the  temporal  and  frontal.  In  the  cerebellum  it  is  the  lateral 
hemispheres  that  are  most  frequently  attacked.  The  seat  of  the 
abscess  has  important  relations  to  the  cause.  Abscesses  due  to 
ear  disease  are  almost  always  either  in  the  temporal  lobe  or  the 
cerebellum.  If  the  ear  disease  is  in  the  tympanum,  the  cerebrum 
is  usually  the  seat  of  the  abscess.  If  the  disease  is  in  the  mastoid 
cells,  the  cerebellum  is  usually  the  part  affected.  If  the  disease 
is  in  the  labyrinth,  the  abscess  is  also  more  apt  to  be  in  the  cere- 
bellum. This  distribution  of  the  seat  of  the  disease  is  due  to  the 
anatomical  relations  of  the  bony  parts  to  the  temporal  lobe  and 
cerebellum,  respectively.  Brain  abscesses  due  to  injuries  are 
more  frequent  in  the  frontal  and  temporal  lobes.     What  are 


350  DISEASES   OF   THE  NERVOUS   SYSTEM. 

known  as  idiopathic  brain  abscesses— that  is,  those  which  arise 
without  any  known  cause— are  most  frequent  inthefrontallobes. 
This  is  because  most  such  cases  are  due  to  an  unrecognized  affec- 
tion of  the  nasal  cavities  and  ethmoid  bone.  Brain  abscesses  due 
to  suppurative  processes  in  the  lungs  and  pleura  are  probably 
embolic;  and  as  the  emboli  are  carried  up  into  the  middle  cere- 
bral artery,  the  brain  abscesses  having  this  origin  are  situated  in 
the  field  supplied  by  this  artery.    In  children  under  ten,  in  whom 


Fig.  178.— Abscess  op  Cerebellum. 

brain  abscess  is  usually  due  to  ear  disease,  the  cerebellum  is  more 
apt  to  be  affected. 

Course. — Acute  abscesses  last  from  five  to  fourteen  days,  rarely 
over  thirty  days.  Traumatic  cases  run  the  shortest  course. 
Chronic  abscesses  may  have  a  latent  period  of  Aveeks,  months, 
and  in  rare  cases  even  one  or  two  years.  When  terminal  symp- 
toms come  on  death  occurs  in  a  few  days.  In  a  few  cases  brain 
abscesses  have  been  spontaneously  evacuated  through  the  nose. 
Aside  from  this,  the  termination  is  always  a  fatal  one  unless  sur- 
gical interference  takes  place.  There  is  sometimes  a  recurrence 
of  the  abscess  after  an  operation. 

Diagnosis.— The  diagnosis  of  brain  abscess  is  based  upon  the 


DISEASES   OF   THE   BRAIN 


351 


history  of  injury,  aural  or  nasal  disease,  remote  suppuration, 
upon  the  general  symptoms  of  sepsis,  upon  the  presence  of  head- 
ache, vomiting,  slow  pulse,  normal  or  subnormal  and  irregular 
temperature,  a  local  tenderness  of  the  scalp  and  rise  of  tempera- 


ture over  the  seat  of  the  lesion,  hebetude,  delirium,  optic  neuri- 
tis, rapid  wasting,  and  diminution  of  chlorides  in  the  urine. 

The  diagnosis  of  the  location  of  the  abscess  is  based  upon  the 
history  of  its  cause,  Avhether  from  injury,  ear  disease,  emboU 
from  the  lungs,  or  nasal  disease ;  also  upon  the  presence  of  hemi- 
plegia, local  convulsions,  tenderness  and  rise  of  temperature  of  a 
certain  area  of  the  scalp.     As  brain  abscesses  are  apt  to  affect 


352  DISEASES   OF  THE   NERVOUS   SYSTEM. 

latent  regions  like  the  temporal  and  frontal  lobes,  local  diagnosis 
is  usually  difficult.  The  diagnosis  must  be  made  from  tumors  of 
the  brain,  meningitis,  and  phlebitis  of  the  sinuses.  The  differ- 
ential points  are  given  under  the  heads  of  the  diseases  mentioned. 

The  prognosis  of  the  disease  is  absolutely  unfavorable  unless 
some  surgical  interference  is  resorted  to.  The  few  rare  cases  of 
spontaneous  evacuation  of  the  abscess  would  not  lead  to  any 
practical  modification  of  this  statement. 

Treatment. — The  actual  treatment  of  a  brain  abscess  after  it 
has  developed  is,  as  already  stated,  exclusively  a  surgical  one. 
The  successes  so  far  have  not  been  very  great,  but  they  have  been 
sufficient  to  justify  operation  and  to  furnish  greater  hope  for  the 
future,  when  a  more  exact  diagnosis  can  be  made  and  a  wider 
surgical  experience  has  been  obtained.  The  accompanying  fig- 
ure shows  the  points  to  be  located  in  trephining  for  abscess  from 
ear  disease.  Something  is  due  to  the  patient  in  the  way  of  pre- 
vention, especially  in  cases  of  persons  who  have  chronic  aural  or 
nasal  disease  with  carious  processes.  These  should  be  carefully 
watched  and  treated. 

Acute  Exudative  Encephalitis  (Acute  Bulbar  Myelitis, 
polioe]\"cephalitis  superior  ak^d  ijfferior,  infan- 
TILE Polioencephalitis,  Primary  Encephalitis  of 
Friedmann). 

Acute  exudative  encephalitis  is  a  disease  whose  pathological 
existence  is  probable,  but  as  yet  we  are  not  able  to  establish  any 
definite  clinical  types  associated  with  the  process.  An  exception 
to  this  may  be  made  in  the  case  of  acute  bulbar  myelitis  and 
acute  polioencephalitis  superior.  A  third  exception  is  claimed 
by  Strumpell,  who  affirms  the  existence  of  an  acute  polioenceph- 
alitis of  children.  A  form  of  acute  non-suppurative  and  primary 
encephalitis  is  described  by  Friedmann,  and  illustrative  cases  are 
given ;  but  as  yet  it  is  doubtful  if  we  can  place  this  condition  in 
the  category  of  a  distinct  disease. 

Acute  bulbar  myelitis  is  a  disease  which  is  strictly  analogous 
in  course  to  acute  myelitis.  The  special  symptoms  simply  depend 
upon  the  peculiar  location  of  the  disease.  They  consist  of  an 
acute  glosso-labio-laryngeal  palsy,  and  are  referred  to  under  the 
description  of  bulbar  paralysis. 

Acute  iDolioencephalitis  superior  is  a  disease  in  which  the 
nuclei  of  the  nerves  supplying  th-e  eye  muscles  are  involved; 
it  is  a  disease  analogous  to  poliomyelitis  anterior,  and  has  been 
described  under  the  head  of  Ophthalmoplegia. 

The  acute  polioeDcephalitis  of  children  (Strumpell)  is  a  dis- 
ease that  involves  the  gray  matter  of  the  convexity  of  one  of  the 


DISEASES   OF   THE   BRAIN.  353 

cerebral  hemispheres.  The  disease  is  supposed  to  be  strictly 
analogous  to  an  inflannuation  of  the  anterior  horns  of  the  spinal 
cord.  It  attacks  children  between  the  first  and  fourth  years  of 
life,  with  symptoms  of  fever,  delirium,  and  often  of  convulsions 
followed  by  a  hemiplegia.  The  acute  symptoms  pass  away  in 
a  week  or  two,  leaving  the  child  with  the  hemiplegia  which  may 
improve  very  greatly,  but  more  commonly  continues  through  life. 
With  it  later  there  are  developed  contractures  of  the  affected 
side,  some  atrophy,  mental  defects,  and  epileptic  convulsions. 
The  real  existence  of  this  disease  is  very  doubtful. 

Chronic  Encephalitis.— Under  the  older  views  of  inflam- 
mation there  were  described  as  chronic  cerebritis  such  lesions  as 
sclerosis  and  cerebral  atrophy.  These  jjrocesses  we  now  regard 
as  being  simply  reparative  and  as  the  sequelae  of  acute  destruc- 
tive or  inflammatory  pro(^esses.  They  will  be  described,  there- 
fore, under  such  heads.  The  only  form  of  chronic  cerebritis  for 
which  there  is  a  recognized  clinical  prototype  is  the  chronic  cor- 
tical cerebritis,  which  is  the  basis  of  general  paralysis  or  paralytic 
dementia.  Even  this  process,  however,  is  still  regarded  by  many  as 
essentially  a  degenerative  one  and  not  inflammatory.  As  the 
symptoms  which  result  from  it  are  those  of  insanity,  the  disease 
will  not  be  described  in  this  work. 


THE  APOPLEXIES. 

Apoplexy  is  a  condition  characterized  by  a  sudden  paralysis 
and  shock,  usually  with  loss  of  consciousness,  and  due  to  the 
breaking  or  blocking  up  of  a  blood-vessel  in  the  brain. 

Apoplexy  is  a  general  term.     Its  particular  forms  are . 

1.  Intracranial  hemorrhage,  from  rupture  of  blood-vessel. 

2.  Acute  cerebral  softening,  from  embolism  or  thrombosis. 
Since  both  embolism  and  thrombosis  cause  a  rapid  softening 

in  the  area  supplied  by  the  obstructed  vessel,  the  term  acute 
softening  covers  both  disorders. 

Apoplexy  from  Intracranial  Hemorrhage  (Cerebral 
Hemorrhage,  Hemiplegia). 

Forms.— There  are  four  groups  of  blood-vessels  in  the  brain, 
those  of  the  dura  mater,  those  of  the  pia  mater,  and  those  sup- 
plying the  basal  ganglia  and  white  matter.  Besides  this,  we  may 
consider  the  pons,  medulla,  and  cerebellum  which  are  supplied 
chiefly  by  branches  of  the  vertebrals  as  a  separate  group,  sub- 
ject to  somewhat  different  mechanical  conditions.  Correspond- 
ing to  this  we  have : 

1.  Dural  or  pachymeningeal  hemorrhages. 

2.  Pial  or  subarachnoid  hemorrhages. 

23 


354  DISEASES   OF   THE   NERVOUS   SYSTEM. 

3.  Central  hemorrhages. 

4.  Hemorrhages  in  the  medulla,  pons,  and  cerebellum. 

It  is  the  central  hemorrhages  (So.  3)  due  to  rupture  of  the 
blood-vessels  going  to  the  great  basal  ganglia,  internal  capsule, 
and  white  matter  that  cause  the  great  majority  of  cerebral  hem- 
orrhages seen  by  the  physician.  It  is  this  class  that  I  have  par- 
ticularly in  mind  in  the  following  description. 

Etiology.— At  the  time  of  birth  and  during  infancy  there  is  a 
slight  tendency  to  intracranial  hemorrhage  owing  to  the  acci- 
dents and  injuries  of  labor.  After  this  period  the  liability  is  very 
small,  but  slowly  increases  up  to  the  age  of  forty,  when  predis- 
position specially  begins.  Four-fifths  of  all  cases  occur  after 
forty,  and  the  tendency  to  hemorrhages  increases  in  each  decade 
up  to  eighty,  when  it  diminishes  absolutely  and  relatively.* 
Males  are  slightly  more  predisposed  than  females  (five  to  four). 
Rather  moi'e  cases  occur  in  cold  weather,  at  high  altitades,  in 
the  temperate  zone,  and  among  civilized  races.  Heredity  has 
an  undoubted,  though  not  great  influence  in  predisposing  to 
cerebral  arterial  disease.  Infective  fevers  and  marasmic  states 
are  predisposing  causes.  Chronic  kidney  disease  is  present  in 
one-third  of  the  cases.  Chronic  alcoholism,  syphilis,  and  gout 
are  powerful  predisposing  causes.  Rheumatism  is  less  impor- 
tant. Heart  disease,  fatty  and  atheromatous  arteries,  arteritis,  and 
miliary  aneurisms  may  be  regarded  as  more  than  simply  predis- 
posing— they  are  determining  causes.  Leucocythsemia,  scurvy, 
and  purpura  are  conditions  which  also  particularly  tend  to  cause 
hemorrhage.  The  so-called  apoplectic  habit — short  thick  neck 
and  high  shoulders  and  florid  face — has  really  some  importance 
in  the  better  classes.  Congenital  anomalies,  such  as  a  narrow  tho- 
racic aorta  or  inherited  deficiency  in  the  strength  of  the  walls  of 
the  blood-vessels,  also  play  a  i^art.  Any  sudden  physical  exer- 
tion, such  as  straining  at  stool,  the  excitement  at  coitus  or  of  a 
passion,  eating  a  large  meal  and  drinking  a  great  deal  of  fluid, 
especially  alcohol,  taking  a  cold  bath,  all  may  lead  to  rupture  of 
an  artery.  Often  the  vessel  breaks  during  sleep,  owing  perhaps 
to  the  contracted  condition  and  consequent  higher  pressure  m 
the  arteries,  and  to  the  fact  that  on  account  of  the  horizontal 
position  there  is  more  resistance  to  the  return  of  the  blood  from 
the  brain. 

The  symjytoms  are  the  prodromal,  those  of  the  attack  and 
acute  stage,  and  those  of  the  chronic  stage. 

*  Among  53  cases  collected  by  me  at  Bellevue  Hospital,  the  agres  were  10 
to  20,  4;  21  to  30,  G  ;  31  to  40,  10  ;  41  to  50,  11  ;  51  to  60.  7  ■  61  to  70.  10;  71  to  60, 
5  The  right  side  was  affected  in  23  cases  ;  left  in  25  cases.  The  location  was . 
Pachymeningeal,  7  ;  pial  and  cortical.  8  ;  ventricular,  23  :  corpus  striatum  and 
vicinit}-,  7  ;  optic  thalamus,  2 ;   corpora  quadrigemiua,  1  ;   pons,  1  ;  cerebellum,  3. 


DISEASES   OF   THE   BRAIN.  355 

Prodromal  symptoms  are  rare  except  in  syphilitic  cases. 
Wlien  present  the  patient  suffers  from  dizziness,  numbness  of  the 
hand  and  foot  on  one  side,  and  a  failure  of  memory  for  words. 
He  may  have  "  full "  feelings  or  even  pain  in  the  head  and  bad 
dreams  at  night.  Nose-bleed  and  irregular  heart  action  sometimes 
occur.  The  attack  always  comes  on  suddenly  and  may  be  ac- 
comiDanied  (1)  with  convulsions  and  coma,  (2)  with  coma  alone, 
or  (3)  without  loss  of  consciousness. 

1.  Initial  convulsions  are  rare  and  generally  mean  a  meningeal 
hemorrhage.  When  present  they  are  unilateral  or  partial,  as  a 
rule,  but  may  be  general.  2.  The  common  mode  of  onset  is  with 
coma.  The  patient,  without  w^arning,  suddenly  becomes  dizzy, 
loses  consciousness,  and  falls.  The  face  is  flushed,  the  pulse  hard 
and  rather  slow,  the  breathing  is  labored  and  stertorous,  the 
cheek  on  one  side  puffs  out  with  each  expiration,  the  eyes  are 
partly  closed,  the  eyeball§  fixed  or  deviated  to  the  paralyzed 
side,  the  pupils  are  contracted  and  rigid,  the  skin  is  bathed  in 
sweat,  the  limbs  are  relaxed,  but  some  evidence  of  hemiplegia  is 
present ;  the  urine  may  be  retained  or  it  and  the  fccces  involun- 
tarily evacuated.  The  urine  is  usually  of  rather  high  specific 
gravity  and  often  contains  albumin,  even  when  there  is  no  renal 
disease.  The  temperature  in  severe  cases  may  fall  below  normal 
during  the  first  twelve  hours,  even  to  96°  F.,  but  this  is  not  the 
rule.  It  is  the  rule,  however,  for  the  temperature  in  a  few  hours 
to  be  1"  or  2"  higher  on  the  paralyzed  than  on  the  sound  side.  If 
the  case  is  rapidly  fatal  coma  continues,  respiration  often  assumes 
a  Cheyne-Stokes  character,  the  pulse  becomes  faster,  the  tempera- 
ture gradually  rises,  and  usually  reaches  102°  or  103°  F.,  until  just 
before  death,  when  it  may  sink  again.  Swallowing  and  speech 
become  difficult,  hypostatic  pneumonia  sets  in,  and  the  patient 
dies  in  from  two  to  four  days.  In  sloAver  fatal  cases  the  patient 
regains  consciousness  partially  and  then  enters  a  condition  of  stu- 
por or  mild  delirium.  He  is  restless  and  suffers  from  headache. 
The  temperature  may  continue  normal  for  a  time,  but  is  usually 
higher  on  the  affected  side.  At  the  end  of  two  or  three  w^eeks 
it  rises  higher,  pneumonia  develops,  the  patient  becomes  uncon- 
scious and  finally  dies.  In  the  favorable  cases,  which  constitute 
the  majority,  coma,  if  present,  gradually  passes  away  in  from  one 
to  six  hours,  leaving  the  patient's  mind  somewhat  w^eak  and 
confused  and  his  speech  disturbed,  or  more  rarely  the  intelligence 
may  not  be  at  all  disturbed.  During  the  first  few  days  or  weeks 
after  the  attack  the  physician  finds  that  the  prominent  symptom 
is  the  hemiplegia.  This  affects  the  arm.  and  leg  most  and  the 
face  least.  Only  the  lower  two  branches  of  the  facial  nerve  are 
involved,  and  the  patient  can  shut  the  eyes.  The  tongue,  if  pro- 
truded, turns  to  the  paralyzed  side ;  the  uvula  is  turned  in  various 


356  DISEASES   OF   THE   NERVOUS   SYSTEM. 

ways  and  its  position  is  of  no  significance.  There  is  often  some 
evidence  of  cutaneous  anaesthesia  of  the  paralyzed  side,  and  less 
often  hemianopsia  and  disturbances  of  hearing  occur.  In  right- 
sided  hemiplegia  the  patient,  after  recovering  consciousness,  is 
often  unable  to  talk  or  to  understand  what  is  said.  Examina- 
tion shows  that  he  has  a  motor  or  sensory  aphasia  (y/fZe  Aphasia). 

The  deviation  of  the  eyes  and  head  to  one  side  usually  dis- 
appears in  a  day  or  two.  Occasionally  there  is  a  temporary 
ptosis.  The  pupils  at  first  are  contracted,  that  on  the  paralyzed 
side  the  more  so ;  this  condition  disappears  with  returning  con- 
sciousness. 

The  paralysis  of  the  arm  and  leg  is  flaccid  at  first,  and  the 
limb  falls  heavily  when  lifted ;  the  reflexes  are  lessened  or  abol- 
ished. 

Sometimes,  however,  rigidity  sets  in  at  once.  This  symptom 
occurs  when  blood  has  broken  into  the  ventricles,  and  also  in 
some  meningeal  hemorrhages.  The  skin  reflexes  are  abolished  or 
nearly  so  on  the  affected  side. 

The  usual  course  of  the  temperature  is  for  it  to  rise  on  the 
second  and  third  day  to  100'  F.  or  102  F.,  being  V  to  1°  F.  higher 
on  the  paralyzed  side.  In  a  few  days  it  gradually  falls,  so  that 
by  the  eighth  to  the  tenth  day  it  is  normal. 

If  the  temperature  continues  to  rise  after  the  fourth  or  fifth 
day,  it  is  a  sign  of  an  extension  or  infiammatory  reaction  of  the 
hemorrhage.  Hence  the  thermometer  furnishes  a  very  important 
criterion  of  the  seriousness  of  the  ease. 

The  varying  course  of  the  apoplexy  is  shown  in  the  following 
diagram ; 

Health  line. 


3.  Chronic  stage. 
4  to  8  weeks. 


Improvement. 


Attack.- 


1.  Death.  2.  Death. 

2  to  4  days.  2  to  4  weeks. 

The  Chronic  Stage,  Hemiplefiia.—M  the  end  of  a  month,  if 
fever  and  s^^mptoms  of  cerebral  irritation  have  subsided,  the 
chronic  stage  may  be  said  to  begin.  The  hemiplegia  has  improved , 
the  patient  can  move  the  leg  and  arm  a  little,  sensory  symptoms 


DISEASES   OF   THE   BRAIN.  357 

have  lessened,  the  mind  is  clear,  headache  has  disappeared.  Im- 
provement continues,  though  more  slowly,  for  several  months  or 
even  one  or  two  years.  During  this  time  the  patient  is  "  a  hemi- 
plegic." 

The  hemiplegia  affects  the  arm  more  than  the  leg  and  the 
face  least  of  all.  The  distal  segments  of  the  limbs,  the  feet  and 
hands,  are  affected  more  than  those  near  the  trunk.  The  mus- 
cles that  act  bilaterally,  such  as  those  of  respiration,  phonation, 
and  facial  expression,  are  but  slightly  involved.  The  paralysis  is 
not  strictly  a  hemiplegia,  for  the  muscles  on  the  sound  side  are 
somewhat  weakened,  as  tests  will  show.  In  severe  cases,  es- 
pecially in  old  people,  even  the  visceral  muscles,  especially  those 
of  the  bladder,  are  weakened.  At  the  onset  of  the  attack  there  is 
sometimes  a  temporary  "  initial "  rigidity  of  the  muscles  on  the 
pai-alyzed  side,  or  an  "  early ''  rigidity  may  develop  in  one  or  two 
days.  There  always  develops  at  about  the  beginning  of  the  sec- 
ond week  a  "  late ''  rigidity.  This,  which  at  first  is  slight,  gradually 
increases,  and  finally  contractures  affect  the  paralyzed  limbs. 
The  superficial  reflexes,  wdiich  at  first  were  absent,  reappear ;  the 
tendon  refiexes  become  much  exaggerated,  and  clonus  can  be 
obtained  in  the  leg  and  arm.  The  sound  side  shares  to  a  small 
extent  in  these  conditions.  The  contractures  affect  the  extensors 
of  tlie  foot  more  than  the  flexors,  and  bring  the  toe  down  and  the 
heel  up.  The  leg  is  held  nearly  extended,  and  the  limb  in  walk- 
ing is  swung  around,  the  toe  scraping  the  ground.  The  shoulder 
is  adducted,  the  forearm  flexed,  and  the  fingers  tightly  shut  into 
the  palm  by  the  overaction  of  the  flexors.  The  facial  muscles 
show  a  slight  contraction  and  drawing  to  the  affected  side.  The 
muscles  on  the  paralyzed  side  do  not  waste.  In  infantile  hemi- 
plegia, however,  the  affected  limbs  grow  less  than  those  on  the 
sound  side. 

The  paralyzed  lin)bs  may  be  the  seat  of  peculiar  disorders  of 
movement.     These  consist  of 

Associated  movements. 

Tremor. 

Ataxia. 

Choreic  movements. 

Continuous  or  athetoid  movements. 

Spastic  movements  and  cramps. 

Such  movements,  aside  from  those  that  are  spastic,  are  rarely 
seen  in  the  hemiplegia  of  adults. 

The  electrical  irritability  may  be  at  first  sightly  increased  and 
diminished,  but  the  change  is  slight  in  amount  and  never  reaches 
the  degenerative  stage. 

Hemianj^sthesia,  if  present  at  first,  disappears  to  a  great  ex- 
tent, leaving  only  residua  about  the  feet  and  hands.     Paraesthe- 


358  DISEASES   OF  THE   NERVOUS  SYSTEM. 

sise  are  common.  In  rare  cases  the  patient  suffers  great  pain  in 
the  arm  and  leg.  This  pain  is  generally  of  a  burning  character 
and  very  obstinate  and  distressing.  Cramping  pains  in  the  legs 
and  arms  are  common  in  the  severer  cases. 

During  the  first  five  weeks  after  the  onset  joint  inflammations 
and  bed-sores  may  attack  the  affected  side.  The  temperature  of 
the  hemiplegic  side  is  usually  a  very  little  higher  than  that  of  the 
sound  side.  ^ 

Vasomotor  disturbances,  sweating,  skin  eruptions,  and  in- 
creased growth  of  hair  are  some  of  the  rarer  symptoms. 

The  mental  condition  is  more  or  less  affected.  The  patient 
becomes  irritable,  cries  easily,  and  is  in  general  more  emotional. 
The  memory  is  impaired,  and  the  poAver  of  concentrating  the 
attention  and  carrying  on  work  is  less.  Sometimes  a  progressive 
mental  deterioration  sets  in  or  insanity  develops.  The  mental 
disturbance  is  greater  in  old  people  and  depends  somewhat  on 
the  size  of  the  hemorrhage.  Those  forms  which  produce  serious 
aphasia  especially  limit  and  lessen  mental  activity. 

Pathology  and  Morbid  Anatomy. — Spontaneous  intracranial 
hemorrhage  is  always  due  to  the  presence  of  diseased  blood-ves- 
sels in  the  brain.     This  diseased  condition  consists  of 

1.  A  degenerative  arteritis' which  results  in  producing  small 
aneurisms.  2.  A  fatty  degeneration  of  the  vessel  walls.  3.  Be- 
sides this,  in  most  cases  the  larger  blood-vessels  are  atheromatous. 

1.  The  arteritis  produces  small  or  miliary  aneurisms  which 
affect  only  the  smaller  arteries,  especially  those  of  the  central 
group.  They  may  be  fusiform  or  sacculated  in  shape ;  they  range 
in  size  from  one-fifth  to  one  millimetre  (^^o  to  it  i^^-)  ^^  diameter. 
They  are  usually  not  very  numerous,  but  there  may  be  as  many 
as  a  hundred  in  the  brain.  They  are  the  results,  not  of  inflam- 
mation, but  of  a  degeneration  which  affects  first  an  area  in  the 
internal  coat;  this  causes  local  weakness  and  consequent  dilata- 
tion ;  secondarily  there  is  a  periarteritis.  These  aneurisms  occur 
almost  exclusively  during  the  degenerative  period  of  life. 

2.  Fatty  degeneration  of  the  walls  of  the  small  cerebral  arteries 
occurs  in  purpura,  scurvy,  leucocythsemia,  marasmic  conditions. 
and  post-infective  states,  especially  in  early  life,  and  is  the  com- 
mon cause  of  liemorrhage  at  that  time. 

3.  Atheroma  affects  the  larger  vessels  only.  It  is  indirectly  a 
cause  of  hemorrhage  by  lessening  the  elasticity  of  the  vessel  wall. 
Atheroma  is  present  in  one-eighth  to  one-fifth  the  cases.  Hyper- 
trophy of  the  heart  is  a  factor  in  causing  hemorrhage,  and  such 
hypertrophy  exists  in  about  forty  per  cent  of  cases.  Emboli 
lodged  in  the  cerebral  arteries  may  cause  hemorrhage  by  sud- 
denly stopping  the  arterial  circulation  and  raising  the  blood 
pressure.     Hemorrhages  are  found  by  far  the  oftenest  (twenty  per 


DISEASES   OF  THE   BRAIN.  359 

cent)  in  the  caudate  and  lenticular  nuclei  and  adjacent  parts. 
The  lenticular  and  lenticulo-striate  branches  of  the  middle  cere- 
bral are  oftenest  affected ;  next  the  branches  of  the  anterior  cere- 
bral to  the  caudate  nucleus  and  the  ventriculo-optic  branches  of 
the  middle  cerebral.  The  branches  of  the  posterior  cerebral 
break  more  rarely.  The  parts  affected  in  hemorrhage,  in  order 
of  frequency,  are  about  as  follows ; 

Caudate  and  lenticular  nuclei. 

Meninges  and  cortex. 

Centrum  ovale. 

Optic  thalamus. 

Pons,  cerebellum,  medulla. 

'Cortex  hemorrhages  are  generally  small  and  may  be  sub- 
arachnoid or  may  break  through  into  the  arachnoid  cavity.  Ven- 
tricular hemorrhages  are  almost  always  secondary  to  a  rupture 
into  the  neighborhood  of  the  basal  ganglia.  Pons  hemorrhages 
occur  usually  in  the  median  line.  Cerebellar  hemorrhages  are 
oftenest  due  to  rupture  of  the  superior  cerebellar  artery.  They 
usually  cleave  their  way  externally  and  break  into  the  fourth 
ventricle.  Dural  hemorrhages  are  due  to  rupture  of  the  menin- 
geal veins  and  arteries  and  of  the  vessels  in  newly  organized  clots. 
They  lie  in  the  arachnoid  cavity  and  flatten  the  convolutions. 

The  reparative  changes  after  a  hemorrhage  take  the  following 
course:  1st.  Coagulation  of  the  blood,  which  in  a  few  days  be- 
gins to  soften  and  become  absorbed.  2d.  Formation  of  a  fibri- 
nous wall  about  the  clot.  This  occurs  from  the  seventh  to  the 
ninth  day.  3d.  Formation  of  a  cyst  with  transparent  fluid  con- 
tents, and  perhaps  fibrous  trabecul*  running  through  it,  twenti- 
eth to  thirtieth  day.  4th.  Contraction  of  the  cyst  wall,  which 
begins  by  the  fortieth  day.  5th.  Secondary  degenerations  begin 
from  the  tenth  to  the  fourteenth  day. 

Physiologi/.— The  blood  pressure  of  the  cerebral  arteries  is 
equal  to  about  150  mm.  of  mercury.  The  resistance  or  support 
furnished  by  the  surrounding  tissue  is  equal  to  about  10  mm.  of 
mercury.  Hence  there  is  a  special  liability  to  rupture  of  intra- 
cranial vessels.  The  middle  cerebrals  are  most  often  affected, 
because  they  are  in  the  most  direct  line  from  the  heart  and  are 
nearest  to  that  organ.  The  pressure  lessens  as  the  arteries  subdi- 
vide and  get  farther  away  from  the  heart  (Mendel). 

The  diagnosis  must  be  made  from  alcoholic  coma,  uraemic 
coma,  opium  coma,  epilepsy  and  hysteria,  acute  softening  from 
embolism  and  thrombosis. 

From  alcoholic  coma  the  diagnosis  is  made  by  the  odor  of  the 
breath,  the  incomplete  coma,  the  equal  pupils,  the  absence  of 
low  or  unequal  temperature. 

From  uremic  coma  by  the  absence  of  albumin  and  casts  in  the 


360  DISEASES   OF  THE  NERVOUS  SYSTEM. 

urine,  though  their  presence  does  not  surely  indicate  uraemia; 
by  the  unequal  pupils,  the  temperature,  the  absence  of  hemi- 
plegia, and  of  the  physiognomy  peculiar  to  cases  of  chronic 
Bright's  disease. 

From  opium-poisoning  by  the  history,  the  stomach  contents, 
the  presence  of  equal  and  contracted  pupils,  the  slow  respirations, 
the  temperature,  and  the  absence  of  paralysis. 

From  epilepsy  by  the  history  of  the  onset  with  epileptic  cry, 
the  dilated  and  equal  puj^ils,  the  biting  of  the  tongue,  the  ab- 
sence of  hemiplegia,  the  rather  rapid  return  of  consciousness. 

Hysterical  attacks  present  little  semblance  to  that  of  apo- 
plexy; hysterical  hemiplegia  is  characterized  by  its  fiaccidity, 
by  its  not  involving  the  face,  and  by  the  presence  of  the  anaes- 
thesia and  other  hysterical  stigmata. 

In  embolic  softening  the  earlier  age  of  the  patient,  the  pres- 
ence of  decided  valvular  heart  disease,  the  parturient  condition, 
the  slighter  degree  and  shorter  duration  of  coma,  the  absence  of 
serious  disturbance  of  temperature,  the  onset  first  of  paralysis 
and  then  of  convulsive  movements  and  coma — all  lead  to  a  pre- 
sumjjtion  in  favor  of  embolism. 

The  presence,  on  the  other  hand,  of  a  congested  face,  tense 
pulse,  and  throbbing  carotids  favors  the  existenf'e  of  a  hemor- 
rhage. 

From  thrombotic  softening  diagnosis  is  more  difficult.  The 
occurrence  of  prodromata,  consisting  of  slight  seizures  quickly 
recovered  from,  the  slighter  degree  of  coma,  the  advanced  age, 
hard  atheromatous  arteries,  evidence  of  anaemia  and  asthenia, 
weak  or  fatty  heart,  the  absence  of  stertorous  respiration,  flushed 
face,  and  unequal  temperature  not  much  lowered  or  raised,  the 
sHght  pupillary  disturbance,  and  absence  of  convulsions  point 
to  thrombotic  softening.  Evidence  of  a  lesion  in  the  pons  or 
cerebellum  suggests  hemorrhage,  while  evidence  of  lesion  in  the 
medulla  points  almost  surely  to  softening. 

The  chances  in  any  case  between  the  ages  of  thirty  and  fifty, 
if  there  is  no  heart  disease,  are  six  to  one  in  favor  of  hemorrhage. 

Prognosis. — The  majority  of  cases  get  over  the  first  attack. 
They  are  very  liable  to  have  another  within  one  to  five  years. 
The  minority  recover  from  this.  Few  survive  a  third  attack. 
The  prognosis  of  the  attack  itself  depends  on  the  severity  of  the 
coma  and  paralysis,  the  disturbance  of  temperature  and  of 
respiration,  the  evidence  of  rupture  into  the  ventricles,  the  de- 
velopment of  decubitus,  the  continuance  of  loss  of  control  over 
the  bowels  and  bladder. 

If  profound  coma  continues  four  days  there  is  little  hope;  if 
fever  develops  and  continues  steadily,  or  if  there  is  initial  sub- 
normal temperature,  the  prognosis  is  grave. 


DISEASES   OF  THE   BRAIN.  3G1 

If  the  patient  passes  the  first  week  with  Httle  or  no  fever  and 
consciousness  has  returned,  the  prognosis  is  good. 

The  presence  of  renal  disease  and  of  alcoholism  is  bad.  De- 
velopment of  shght  delirium  which  continues  is  unfavorable. 

Cerebellar  and  pons  hemorrhages  are  very  fatal,  meningeal 
slightly  less  so. 

The  prognosis  of  the  chronic  stage  has  been  given  under 
symptoms. 

Improvement  continues  rather  rapidly  for  three  months,  then 
very  slowly.  Improvement  may  continue  for  one  or  two  years. 
Complete  recovery  is  very  rare.  The  great  danger  after  middle 
age  is  recurrence  of  the  attack. 

Treatment  of  the  Attack.— The  patient  should  be  laid  in  a  hor- 
izontal position  and  kept  quiet.  Ice  should  be  applied  to  the 
head  and  hot  bottles  at  the  feet.  The  feet  and  legs  should  be 
swathed  in  clothes  wrung  out  in  hot  water  containing  mustard, 
a  cupful  to  a  pail  of  water.  A  laxative  should  be  given,  either 
one  or  two  drops  of  croton  oil  or  a  quarter  of  a  grain  of  elaterium. 
If  there  is  evidence  of  intense  cerebral  congestion,  the  pulse  being 
very  full  and  hard  and  the  heart  beating  strongly,  bleeding  eight 
to  ten  ounces  is  justifiable.  Ordinarily  it  is  better  to  give  a  drop 
of  tincture  of  aconite  every  twenty  minutes  for  two  or  three 
hours.  Pressure  on  the  carotid  of  the  sound  side,  and  even  liga- 
ture of  it,  has  been  recommended,  but  there  is  no  experience  yet 
to  justify  it.  Administration  of  bromide  of  sodium  and  enemata 
of  ergot  have  been  advised,  but  are  of  doubtful  value.  After  the 
first  twelve  hours  treatment  must  be  symptomatic.  Should  de- 
lirium and  other  evidence  of  mental  irritation  appear,  large  blis- 
ters must  be  applied  at  the  back  of  the  neck  and  an  elaterium 
purge  given  if  the  patient  is  not  too  weak.  The  use  of  iodide  of 
potassium  or  mercury  is  not  indicated  unless  the  case  is  dis- 
tinctly syphilitic.  The  passage  of  a  galvanic  current  through 
the  brain  cannot  possibly  do  any  good.  Great  care  should  now 
be  taken  that  the  patient  does  not  develop  pneumonia.  The 
mouth  and  pharynx  should  be  cleansed  antiseptically,  and  the 
patient  should  not  be  allowed  to  remain  in  one  position.  If 
there  is  sufficient  evidence  of  a  meningeal  or  cortical  clot,  tre- 
phining should  be  seriously  considered. 

At  the  end  of  three  or  four  weeks  the  faradic  battery  may  be 
used  carefully  on  the  affected  limbs.  A  seance  of  fifteen  minutes 
daily  for  four  to  six  weeks  should  be  given,  then  treatment  should 
be  suspended  for  a  fortnight,  to  be  begun  again  and  kept  up  sys- 
tematically for  a  year  if  need  be.  Massage  may  be  alternated 
with  the  electricity.  When  contractures  develop  the  stabile  gal- 
vanic current  may  be  tried,  though  it  does  little  good.  Static 
sparks,  however,  are  helpful :   lukewarm  baths  should  be  tried ; 


362  DISEASES  OF  THE  NERVOUS   SYSTEM. 

and  measures  used  to  produce   liyperextension  of  the  affected 
parts. 

Internally  during  this  time  the  patient  is  to  be  given  courses 
of  iodide  of  iDotassiam,  tonics,  and  laxatives  if  needed.  The  pa- 
tient should  be  made  to  live  a  quiet  life,  preferably  in  a  warm, 
equable  climate.  The  kidneys  should  be  kept  active  and  arterial 
tension  low.  For  these  purposes  nitroglycerin  should  be  given 
and  at  times  small  doses  of  chloral,  and  the  diet  should  be  simple 
and  rather  non-nitrogenous.  Strychnine  in  very  small  doses  (gr. 
YQo)  sometimes  helps  the  contractures;  so  also  do  the  bromides 
and  physostigma. 

Acute  SoFTE^'ING  of  the  Brain  (Embolism,  Thrombosis). 

Acute  softening  is  a  condition  caused  by  the  plugging  of  a 
blood-vessel  with  an  embolus  or  thrombus,  and  is  characterized 
])y  a  sudden  apoplectic  seizure ;  the  symptoms  eventually  running 
a  course  like  that  of  cerebral  hemorrhage. 

Etiology. — Embolism  occurs  rather  more  often  in  women, 
thrombosis  in  men.  Embolism  is  rare  in  children ;  it  occurs  often, 
est  between  the  ages  of  twenty  and  fifty,  thrombosis  between  the 
ages  of  fifty  and  seventy.  The  most  important  predisposing 
factors  in  embolism  are  acute  or  recurrent  endocarditis,  infec- 
tious fevers,  profound  anaemia,  pregnancy,  and  blood  dyscrasl^e; 
in  thrombosis,  syphilitic,  lead,  or  gout}'  arteritis,  fatty  heart,  and 
blood  dyscrasise.  The  same  causes  which  lead  to  the  arterial  dis- 
ease which  produces  cerebral  hemorrhage  also  predispose  to 
thrombosis ;  though  in  the  latter  condition  atheroma  plaj^s  the 
important  part. 

Symptoms. — In  embolism  there  are  rarely  any  premonitory 
symptoms ;  the  onset  is  sudden ;  it  may  begin  with  some  con- 
vulsive twitchings,  then  follow  hemiplegia  and  temporary  loss  of 
consciousness.  Coma,  however,  is  rarer  than  in  hemorrhage,  and 
if  present  is  usually  shorter.  There  is  rarely  vomiting,  nor  do 
we  find  the  hard,  pulsating  arteries,  flushed  face,  and  severely 
stertorous  breathing.  The  initial  temperature  changes  are  slight, 
but  in  a  few  days  fever  may  develop. 

In  thrombosis  premonitory  symptoms  are  frequent.  In 
syphilitic  cases  there  are  headaches  and  cranial  nerve  palsies. 
In  other  cases  vertigo,  temporary  aphasia,  transient  hemi- 
plegia, numbness  of  the  hand  and .  foot,  and  drowsiness  may 
be  present.  The  onset  is  more  gradual ;  the  hemiplegia  slowly 
develops,  taking  several  hours,  perhaps,  for  its  completion; 
meanwhile  the  patient  gradually  becomes  comatose.  The  at- 
tack sometimes  is  rather  sudden,  with  no  loss  of  consciousness, 
and    it    may   occur   in    sleep.      The   teujperature    often    has    a 


DISEASES   OF   THE   BRAIN.  363 

slight  initial  fall,  followed  by  a  rise,  just  as  in  hemorrhage.  In 
both  embolism  and  thrombosis  the  hemiplegia  tends  to  im- 
prove very  much  in  a  few  days  or  weeks  unless  the  vessel  ob- 
literated is  a  large  one.  Embohsm  is  rather  more  apt  to  affect 
the  left  side  of  the  brain,  though  the  difference  is  not  great.  The 
middle  cerebrals  are  most  frequently  affected  (seventeen  out  of 
twenty-seven  cases).  Softenings  affect  the  vertebrals,  basilar, 
and  posterior  cerebral  arteries  more  often  relatively  than  do  hem- 
orrhages ;  then  the  initial  symptoms  may  not  present  the  char- 
acter of  hemiplegia,  but  of  a  bulbar  paralysis.  Acute  softening 
may  kill  within  twenty-four  hours,  but,  as  a  rule,  the  patient 
survives  the  onset,  and  if  he  dies  it  is  not  for  several  weeks.  After 
the  acute  stage  is  over  the  patient  passes  into  the  chronic  stage, 
which  resembles  in  nearly  all  respects  that  of  hemorrhage.  After 
an  acute  softening,  however,  it  is  believed  that  there  are  more 
spastic  symptoms  and  a.  greater  tendency  to  mobile  spasm.  In 
embolism,  owing  to  the  youth  and  freedom  from  arterial  disease, 
the  mind  is  less  affected ;  v.diile  in  thrombosis  the  contrary  is  the 
case. 

Pathology. — The  embolic  plug  cuts  off  the  blood  supply  from 
a  certain  area  of  brain  tissue.  In  twenty-four  hours  this  begins 
to  soften.  If  the  area  is  in  the  cortex  it  becomes  red  (red  soft- 
ening); if  in  the  white  and  less  vascular  i^art,  it  is  usually  white 
with  a  few  red  punctate  spots.  The  red  softening  gradually  be- 
comes yellow  (yellow  softening).  The  dead  tissue  softens  and  is 
absorbed,  leaving  a  cicatrix  or  cyst.  If  the  embolus  contains  in- 
fective microbes  there  may  be  a  local  encephalitis  and  abscess. 

In  thrombosis  there  are  usually  evidences  of  extensive  athe- 
roma or  of  syphilitic  arteritis.  In  those  instances  in  which  the 
thrombosis  is  caused  by  the  blood  state  and  a  weak  heart,  little 
arterial  change  occurs.  Atheroma  affects  chiefly  the  internal 
carotids  and  the  large  arteries  at  the  base,  viz.,  the  middle,  an- 
terior, and  posterior  cerebrals  and  the  basilar  and  vertebrals. 
Thrombosis  with  apoplexy  occurs  oftenest  in  the  corpora  striata 
and  optic  thalamus,  next  in  the  pons  and  medulla.  Embolism 
almost  always  affects  the  great  basal  ganglia  or  some  cortical 
branch  of  the  anterior  and  middle  cerebrals.  The  secondary 
changes  after  thrombosis  resemble  those  after  embolism;  a 
thrombus, however,  may  lead  to  supplementary  embolism  through 
breaking  off  of  a  clot,  and  both  conditions  may  cause  a  complicat- 
ing cerebral  hemorrhage. 

The  Diagnosis.— The  important  points  have  been  gone  over 
under  the  head  of  hemorrhage.  They  may  be  tabulated  in  part 
here. 


364  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Hemorrhage. 

Age,  thirty  to  fifty. 
Hereditary  history  of  arterial  disease. 

Sudden  onset,  with  coma  and  paralysis  occurring  together,  the 
coma  deepening. 

Initial  and  early  rigidity. 

Very  unequal  pupils. 

Stertorous  breathing  and  hard,  rather  slow  pulse. 

Peculiar  alternating  conjugate  deviation. 

Early  rigidity. 

Peculiar  disturbances  of  temperature,  as  described. 

Acute  Softenixg. 

Earlier  or  later  age. 

History  of  syphilis. 

Premonitory  symptoms  and  more  gradual  onset,  more  transi- 
tory coma,  or  absence  of  coma. 

Initial  convulsive  movements. 

Presence  of  weak  heart  or  endocarditis. 

Slight  hemiplegia  Avith  anaesthesia. 

The  puerperal  state. 

Embolism  is  distinguished  by  the  age,  the  presence  of  endo- 
carditis, of  the  puerperium,  or  infective  fevers,  and  by  the  sud- 
den onset,  with  perhaps  some  convulsive  movements.  Thrombo- 
sis occurs  oftener  in  the  aged,  and  there  are  prodromata — a  slower 
onset  and  evidence  of  arterial  disease  and  a  weak  heart. 

The  pi'ognosu- £is  regards  the  attack  is  somewhat  better  than 
in  hemorrhage  as  a  rule.  In  embolism  it  is  good  as  regards  re- 
currence ;  in  thrombosis,  bad.  The  mental  condition  is  better  in 
embolism ;  usually  Avorse  in  thrombosis.  The  recovery  from  at- 
tacks is  more  complete  in  acute  softening.  After  the  chronic 
stage  is  reached,  however,  the  prognosis  is  about  the  same  in  all 
forms. 

The  treatment  of  the  attacks  consists  essentially  in  rest  and 
such  attention  to  the  bowels,  kidneys,  and  heart  as  may  be  indi- 
cated. In  thrombosis  it  may  be  important  to  give  heart  stimu- 
lants and  arterial  depressants,  and  for  this  purpose  I  advise  the  use 
of  alcohol,  digitalis,  or  strophanthus  with  nitroglycerin.  Iodide 
of  potassium  and  mercury  ought  to  be  given  if  there  is  the  slight- 
est suspicion  of  syphilis.  Later  it  is  well  to  give  courses  of  the 
iodides  and  mercury  and  of  strophanthus,  nitroglycerin,  strych- 
nine, and  such  tonics  as  may  be  indicated.  The  symptomatic 
treatment  of  the  chronic  stage  is  the  same  as  in  hemorrhage. 


DISEASES   OF   THE   BRAIN.  365 


Cerebral  Palsies  of  Children— Hemiplegia,  Double 
Hemiplegia  or  Diplegia,  a^d  Paraplegia. 

The  brain  palsies  of  early  life  show  themselves  in  the  form  of .  1, 
hemiplegias;  2,  diplegias  or  double  hemiplegias,  in  which  both 
sides  of  the  body  are  involved;  and,  3,  paraplegias,  in  which  the 
lower  limbs  are  chiefly  or  entirely  involved.  In  these  palsies,  as  in 
the  same  troubles  of  adult  life,  the  loss  of  motor  power  is  always 
accompanied  with  a  rigidity  and  with  some  contractures  and  exag- 
geration of  reflexes,  in  this  respect  distinguishing  these  paralyses, 
from  those  of  spinal  origin.  The  seat  of  lesion  in  these  cases  is. 
in  the  hemispheres  of  the  brain,  and  it  is  the  upper  motor  seg- 
ment which  is  involved ;  that  is  to  say,  that  part  of  the  motor 
tract  w^hich  extends  from  the  brain  cortex  dov/n  to  the  spinal 
cord  as  far  as  the  anterior  horns.  The  brain  palsies  of  children 
are  therefore  disorders  of  the  cortico-spinal  segment,  while  the 
spinal  palsies  of  children  are  disorders  of  the  neuro-spinal  seg- 
ment. 

Etiology, — The  disease  occurs  rather  oftener  in  males  than  in 
females,  though  the  difference  is  slight.  The  vast  majority  occur 
in  the  first  three  years  of  life ;  about  one-third  of  them  are  con- 
genital. Injuries  to  the  mother  during  the  time  of  pregnancy, 
possibly  diseases  and  emotional  disturbances  at  this  time,  are 
factors  in  producing  the  congenital  cases.  Those  cases  that  occur 
at  the  time  of  birth  are  due  to  tedious  labor,  the  use  of  forceps, 
and  other  injuries  at  the  time  of  parturition.  After  birth,  the 
causes  are  those  which  lead  to  the  production  of  intracranial 
hemorrhages,  embolism,  and  thrombosis;  these  being  injuries 
and  the  infectious  fevers.  Of  the  latter,  pneumonia,  whooping- 
cough,  measles,  and  scarlet  fever  are  the  most  prominent.  Syph- 
ilis is  a  rare  cause ;  cerebro-spinal  meningitis  and  epileptic  con- 
vulsions are  also  occasional  causes. 

Symptomatology. — The  disorder  in  about  one-fourth  of  the 
cases  begins  with  a  convulsion,  which  may  be  unilateral,  but  is 
usually  general  in  character,  and  may  last  for  several  hours.  At 
the  same  time  a  febrile  process  develops,  and  this  continues  for 
several  days.  When  these  acute  symptoms  have  subsided,  or  be- 
fore this,  it  is  noticed  that  the  child  is  paralyzed  upon  one  side, 
the  paralysis  involving  the  arm,  leg,  and  face  as  in  adult  hemi- 
plegia, or  perhaps  involving  both  sides.  This  paralysis  under- 
goes gradual  improvement,  the  face  recovering  earliest  and  most, 
the  leg  next,  and  the  arm  least.  As  the  child  develops  it  is  found 
that  the  paralyzed  side  fails  to  grow  as  fast  as  the  other,  and 
there  may  be  half  an  inch  to  one  or  two  inches  of  shortening  in 
the  arm  or  leg.     The  circumference  of  the  limbs  is  less,  the  sur- 


366 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


face  someAvhat  colder,  and  some  vasomotor  disturbance  may  be 
present.  With  tiie  progress  of  the  case  a  rigidity  of  the  affected 
limbs  develops :  the  heel  becomes  drawn  up,  so  that  there  is  talipes 
equino-varus  or  equino-valgus.  The  flexors  of  the  forearm  and 
of  the  wrist  and  fingers  contract,  as  do  also  the  adductors  of  the 
thighs.  In  general  it  will  be  found  that  there  is  a  contraction  of 
the  flexors  and  adductors  of  the  affected  limbs.  With  this  rigidity 
and  the  contractures  there  is  an  exaggeration  of  reflexes  and 
clonus  in  most  cases.  In  the  disordered  limbs  the  peculiar 
mobile  spasms  develop.  These  consist  of  athetoid,  choreic, 
and  ataxic  movements,  also  sometimes  tremors  and  associated 


Fig.  180.  — r 


THETosis.  Beginning  in  Childhood. 


movements.     The  choreic  and  athetoid  movements  are  the  most 
common  (Fig.  180). 

Along  with  the  development  of  these  symj^toms  it  is  noticed 
that  there  are  disturbances  in  the  mental  condition  of  the  child. 
It  is  usually  backward  in  development,  this  backwardness  rang- 
ing from  simply  a  feeble-mindedness  to  complete  idiocy.  Taking 
all  cases,  there  is  about  an  equal  division  between  feeble-minded- 
ness,  imbecility,  and  idiocy  (Sachs).  Perhaps  a  little  over  one- 
fourth  of  the  cases  have  a  fair  intelligence.  There  is  usually 
slowness  in  learning  to  talk,  and  in  a  small  i)roi)ortion  of  cases 
there  is  a  decided  aphasia.  Such  condition  is  rather  more  fre- 
quent with  right  hemiplegia  than  with  left  iiemi|>logia,  though 
the  rule  is  not  an  absolute  one.  In  connection  with  the  mental 
defect  there  may  develop  many  of  the  peculiar  moral  traits  as- 


DISEASES   OF  THE   BRAIN.  367 

sociated  with  idiocy  and  low  degrees  of  intelligence.  Epilepsy 
very  frequently  complicates  the  disease;  nearly  one-half  of 
the  cases  suffer  from  this  trouble.  This  epilepsy  is  in  most  cases 
general  in  character;  in  a  few  cases  it  takes  the  Jacksonian 
type,  in  a  small  number  pe^/^  waZ  alone  is  noted.  Examination 
of  this  class  of  sufferers  reveals,  aside  from  the  paralyses  de- 
scribed, various  evidences  of  defective  development.  These  are 
known  as  stigmata  of  degeneration;  though  they  cannot  be 
classed  strictly  among  such,  since  they  are  acquired  stigmata 
in  most  cases,  rather  than  marks  which  are  the  result  of  primary 
deficiency  in  development.  These  stigmata  consist  of  a  micro- 
cephalic or  a  macrocephalic  skull,  cranial  and  facial  asymmetry, 
prognathism,  imperfectly  develoj^ed  teeth,  and  a  high  palatal 
arch.  It  has  been  found  that,  as  a  rule,  in  cases  of  cerebral 
hemiplegias  of  childhood  the  patient  eventually  has  a  slight  flat- 
tening of  the  skull  on  the  side  of  the  lesion  (Fisher  and  Peterson). 
Finally,  in  a  few  cases  there  may  be  found  defects  in  the  special 
senses,  such  as  imperfect  hearing,  deafness,  deaf -mutism,  and  de- 
fects in  vision  such  as  hemianopsia,  and  perhaps  imperfections 
in  smell  and  taste.     Anaesthesia  is  never  observed. 

The  symptoms  in  the  cerebral  palsies  of  children  having  passed 
the  acute  stage  and  having  become  somewhat  ameliorated,  enter 
into  a  chronic  stage.  This  chronic  stage  begins  within  a  few 
months  after  birth  or  after  the  onset  of  the  disease.  Ts^o  groat 
change  occurs  in  the  paralyses  as  the  child  grows  older  until  he 
reaches  the  time  of  puberty,  though  there  is  a  slight  improve- 
ment in  most  cases  After  the  time  of  puberty,  if  the  mental 
condition  of  the  child  is  good,  the  physical  symptoms  are  apt  to 
improve  considerably. 

Morbid  Anatomy. — The  primary  changes  that  lead  to  the  cere- 
bral i)alsies  of  children  are-  1st,  simj^le  agenesis  or  lack  of  brain 
development,  producing  localized  atrophy  of  the  cerebrum  and 
the  condition  known  as  porencephalus.  True  porencephalas  is  a 
condition  in  which,  owing  to  a  congenital  defect  in  nutrition,  a 
cavity  or  depression  exists  in  the  cerebral  hemispheres,  this  cav- 
ity reaching  generally  into  the  lateral  ventricle.  True  poren- 
cephalus is  found  in  about  one-fourth  of  the  cases,  tliough  no 
definite  statistics  can  be  given,  owing  to  the  different  interpreta- 
tions given  to  this  term ;  2d,  hemorrhage,  which  is  probably  the 
most  frequent  of  the  single  causes;  3d,  embolism;  4th,  throm- 
bosis; 5th,  meningoencephalitis  and  perhaps  polioencephalitis; 
6th,  a  diffuse  cortical  sclerosis.  Many  other  terms  are  used  to 
describe  the  pathological  conditions  found  at  the  basis  of  the 
brain  palsies  of  children;  but  the  principal  causes  of  all  are  un- 
doubtedly as  has  been  described— hemorrhages,  embolism  and 
thrombosis,  and  a  defective  development  or  agenesis.     It  is  prob- 


368 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


able  that  in  the  heiiiiplegies  the  original  lesion  is  generally  a 
central  hemorrhage,  less  often  a  meningeal  hemorrhage.  After 
this,  iDrobably  the  most  frequent  condition  is  a  porencephalus 
from  some  intrauterine  accident  which  may  have  been  defective 
nutrition  causing  ansemia  and  softening,  or  hemorrhage  or  throm- 
bosis. Polioencephalitis  or  inflammation  of  the  cortex  of  the 
brain  of  the  kind  similar  to  poliomyelitis  is  alleged  to  be  a  cause 
in  some  cases  by  Strumpell,  but  this  has  not  yet  been  proven.  In 
double  hemiplegias  or  diplegias  of  children  the  cause  is  in  the 


Fig.  181.— Atrophied  Brain  with  Sclerosis  and  a  Cyst,  from 
Infantile  Cerebral  Hemiplegia. 


Case  of 


vast  majority  of  cases  a  meningeal  hemorrhage  due  to  some  in- 
jury or  disturbance  at  the  time  of  labor.  In  other  cases  of  di- 
IDlegia  the  lesion  is  a  double  porencephalus,  which  may  be  either 
the  result  of  an  intrauterine  hemorrhage  or  simply  a  defective 
development.  In  the  paraplegias  the  lesion  is  probably  very 
much  the  same  as  in  the  diplegias,  that  is  to  say,  either  a  menin- 
geal hemorrhage  or  a  true  porencephalus.  Occasionally  a  diffuse 
sclerosis  has  been  found  in  these  cases.  Not  infrequently,  as  the 
result  of  hemorrhages,  there  develop  cysts  which  fill  up  the  atro- 
phied areas  of  the  brain  (Fig.  181).  It  is  difficult  to  present  accu- 
rately and    definitely   the    relations   between   the   pathological 


DISEASES   OF   THE   BRAIN.  369 

change  and  the  chnical  result,  but  it  may  be  shown  with  some 
degree  of  correctness  in  the  following  table  • 


Original  Lesion. 

Later  Pathological  Condition. 

Clinical  Result. 

Hemorrhage. 
Embolism. 
Thrombosis. 
Agenesis. 

Atrophy. 
Lobar  sclerosis. 
Cysts. 

Porencephaly. 
Microcephaly. 

Hemiplegia. 
Diplegia. 
Paraplegia. 
Sensory  defects. 
Mental  defects. 
Epilepsy,  etc. 

Diplegia  or  Birth  Palsies.— That  form  of  the  brain  pal- 
sies of  childhood  characterized  by  double  hemiplegias  or  di- 
plegias has  certain  special  characters  which  lead  to  its  being 
often  classed  apart.  These  diplegias  in  almost  all  cases  are  con- 
genital and  are  due  either  to  injuries  at  the  time  of  birth  or  to 
some  disorders  of  intrauterine  life.  There  may  be  convulsions 
or  a  prolonged  state  of  asi^hyxia  at  the  time  of  birth.  After  re- 
covery from  this  no  special  trouble  is  noticed  with  the  child  by 
the  mother  for  some  weeks  or  months,  when  it  will  be  found  that 
't  does  not  use  its  arms  or  legs.  Other  convulsions  develop,  and 
eventually  the  features  of  a  double  hemiplegia  with  mental  im- 
pairment and  epilepsy  are  observed  (Figs.  182,  183).  In  these  cases 
the  mental  defect  is  much  more  decided  than  in  the  hemiplegias ; 
indeed,  few  of  these  cases  ever  show  any  good  amount  of  intelli- 
gence. Ej)ilepsy  is  extremely  common.  The  anatomical  lesion 
in  the  cases  is,  as  already  stated,  either  a  meningeal  hemorrhage 
which  has  pressed  upon  and  injured  the  cortical  motor  areas  in 
each  hemisphere  or  it  is  a  congenital  porencephalic  defect. 

Spastic  Cerebral  Paraplegia.— In  a  few  cases  the  brain 
lesion  is  such  that  there  results  very  little  disturbance  to  the 
arms  or  face,  and  the  paralysis  is  almost  entirely  confined  to  the 
low^er  extremities.  Such  cases  w^ere  once  described  as  spastic 
paraplegias  of  childhood  and  thought  to  be  due  to  lesions  in  the 
spinal  cord.  There  is  little  doubt,  however,  now  that  the  pri- 
mary trouble  is  in  all  cases  a  bilateral  lesion  of  the  cerebral  hemi- 
spheres with  a  descending  degeneration  affecting  a  portion  of  the 
lateral  columns  of  the  cord.  In  these  cases  there  are  rigidity  and 
contractures,  club  foot,  exaggerated  reflexes  and  spasms  of  the 
flexors  and  the  adductors,  so  that  the  child's  legs  cross  each  other 
and  interfere  in  its  feeble  attempts  at  walking.  Spastic  para- 
plegia is  usually,  like  diplegia,  a  birth  palsy  and  due  to  the  same 
causes.  It  seems  also  to  be  associated  with  defective  intelligence 
to  about  the  same  degree  as  with  diplegias.  Epilepsy  also  is 
connnon  with  this  type  of  the  disease. 

Diagnosis.— The  clinical  diagnosis  of  cerebral  palsies  is  to  be 
made  from  the  spinal  palsies.     The  latter  are  distinguished  by  the 

24 


370 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


fact  that  ill  the  paralyses  of  spinal  origin  there  is  no  rigidity  or 
exaggeration  of  reflexes,  and  there  are  electrical  degenerative 
reactions  of  the  muscles  and  decided  wasting  of  the  limbs  with 
shortening.  The  mode  of  onset  in  cerebral  palsies  and  their  dis- 
tribution in  the  form  of  hemiplegias  in  which  the  face  is  involved 
also  indicate  the  seat  of  the  lesion.     The  pathological  diagnosis 


Fig.  182.  Fig.  183. 

Figs.  182  and  183.— Cerebral  Diplegia  with  Contractures  and  Talipes. 

Fig.  182  standing  ;  Fig.  183  suspended  by  arms. 

is  bj'  no  means  an  easy  one.  Cerebral  palsies  occurring  at  the 
time  of  birth  and  accompanied  at  that  time  with  general  convul- 
sions or  asphyxia  may  be  considered  to  be  due  to  meningeal  hem- 
orrhage, especially  if  the  delivery  of  the  child  has  been  brought 
about  by  the  use  of  forceps  or  if  the  labor  has  been  long  and 
tedious.  Diplegias  and  paraplegias  which  are  congenital  are 
probably  due  to  true  porencephalus,  provided  there  was  no  diflBl- 


DISEASES   OF  THE   BRAIN.  371 

culty  at  the  time  of  labor  and  no  convulsions  or  other  serious 
phenomena  after  it.  Cerebral  palsies  occurring  after  birth  in 
the  first,  second,  or  third  year  of  life  are  apt  to  be  due  to  hemor- 
rhage, and  less  often  to  embolism,  or  thrombosis.  Hemiplegias 
developing  after  infectious  fevers  are  likely  to  be  due  to  hemor- 
hage.  In  diagnosticating  the  pathological  lesion  in  such  cases 
it  must  always  be  remembered  that  the  hemorrhage  is  much 
more  frequent  than  embolism,  and  that  thrombosis  as  a  factor 
has  not  yet  been  ve:y  clearly  established. 

Course  and  Prognosis.— In  all  types  of  the  disease  the  course 
is  chronic  and  perfect  cure  is  hardly  possible,  although  in  the 
slighter  forms  of  hemiplegia  nearly  all  traces  of  the  paralysis  may 
be  absent.  In  the  hemiplegic  form  the  patient  often  reaches 
adult  life,  and  if  his  intelligence  is  not  defective  and  he  has  no 
epilepsy,  the  motor  trouble  improves  a  great  deal  and  he  may 
live  a  long  and  useful  life.  If  epilepsy  and  mental  defect  are 
present,  there  ensues  eventually  a  further  mental  deterioration, 
and  such  cases  rarely  live  much  beyond  the  i^eriod  of  adoles- 
cence, or  if  they  do  they  pass  into  the  asylums  for  the  idiotic 
and  epileptic.  The  diplegic  and  paraplegic  cases  have  a  inuch 
worse  prognosis  both  as  to  duration  of  life  and  as  to  improve- 
ment in  symptoms.  The  degree  of  intelligence  and  the  absence 
of  epilepsy  are  the  two  factors  wdiich  measure  the  seriousness  of 
these  cases,  as  they  do  those  of  the  hemiplegias.  As  regards  the 
significance  of  individual  symptoms,  the  post-hemiplegic  move- 
ments have  a  bad  import ;  the  presence  of  a  microcephalic  head 
or  of  decided  marks  of  degeneration  is  unfavorable. 

Treatment. — The  treatment,  so  far  as  the  paralj'sis  is  con- 
cerned, is  largely  mechanical.  The  i^atient  is  benefited  by  occa- 
sional courses  of  electrical  treatment  which  stimulate  somewhat 
the  nutrition  and  functions  of  the  muscles.  Massage  and  stretch- 
ing of  the  contract ured  tendons  and  limbs  also  are  helpful  in  my 
experience.  The  orthopedic  surgeon  is  able  to  render  valuable 
assistance  by  occasional  overstretching  of  the  contractured  limbs 
and  placing  them  in  splints.  Tenotomy  may  also  be  resorted  to 
with  advantage,  as  I  have  had  occasion  to  see.  The  child  should 
be  encouraged  above  all,  however,  to  use  the  limb  as  much  as  pos- 
sible. He  should  be  taught  gymnastic  exercises ;  running,  walk- 
ing, and  bicycle-riding  are  all  measures  wiiich  give  great  help. 
When  the  child's  intelligence  is  good  and  there  is  little  or  no  epi- 
lepsy, a  great  deal  can  be  expected  in  the  way  of  improvement  as 
the  child  grows  older. 

So  far  as  the  epilepsy  is  concerned,  it  should  be  treated  on  the 
same  principles  as  idiopathic  epilepsy,  except  that  great  care 
should  be  had  in  the  use  of  the  bromides;  a  thorough  test  must 
be  made  in  order  to  determine  how  much  of  this  drug  will  sup- 


372  DISEASES   OF  THE   NERVOUS   SYSTEM. 

press  the  fits,  and  then  its  use  must  be  graduated  in  the  future  in 
accordance  with  the  knowledge  thus  obtained.  Tlie  mental  de- 
fects of  the  child  can  only  be  helped  by  proper  training  of  the 
body  and  careful  education  of  the  mind.  The  question  of  oper- 
ative interference  in  these  cases  has  of  late  excited  much  atten- 
tion. A  priori  it  would  not  seem  as  though  surgical  interference 
could  do  good  in  relieving  conditions  in  which  there  is  destroyed 
or  atrophic  tissue.  Still  the  subject  must  be  dealt  with  em- 
pirically, and  there  have  been  some  results  which  show  that 
apparently  a  relief  is  obtained  in  a  few  cases  by  trephining  the 
skull  or  by  Lannelongue's  operation  of  craniectomy.  If  there  is 
no  microcephalus,  if  the  case  is  one  of  hemiplegia  with  imbecility 
and  epilepsy,  the  surgeon  should  simply  make  an  exploratory 
opening.  If  he  then  finds  any  evidences  of  compression  from 
the  presence  of  a  cyst,  this  may  be  very  cautiously  opened.  If 
there  is  microcephalus,  the  linear  craniectomy  is  the  operation 
which  is  indicated.  This  has  been  found  to  be  a  very  serious 
surgical  measure  and  should  only  be  resorted  to  with  great  cau- 
tion. In  all  cases,  in  operating  on  children,  it  has  been  found 
that  it  is  imperative  that  the  operation  be  made  as  short  as  pos- 
sible, and  that  as  little  be  done  at  any  single  operation  as  is  con- 
sistent with  the  indications. 


CHAPTER   XIX. 

DEGENERATIONS  AND   SCLEROSES. 

Degeneration  of  the  brain  tissue,  as  in  the  case  of  the  cord 
tissue,  leads  to  sclerosis.  Destruction,  necrosis,  injuries  from  any 
cause,  lead  also  to  sclerosis.  Sclerosis  is  sometimes  a  primary 
change  due  to  a  gradual  proliferation  and  increase  of  connective 
tissue  and  neuroglia  tissue.  We  have,  therefore,  in  the  brain 
primary  degenerations  and  scleroses  and  secondary  scleroses. 
The  primary  degenerations  are  bulbar  palsy  and  ophthalmo- 
plegia externa,  or,  as  these  diseases  are  sometimes  called,  polio- 
encephalitis inferior  and  polioencephalitis  superior;  besides 
these  are  paralytic  dementia,  which  is  a  diffuse  cortical  sclerosis, 
and  disseminated  sclerosis;  and  finally,  underlying  epilepsy  we 
have,  it  is  believed,  a  diffuse  increase  of  neuroglia  tissue  which  has 
been  called  a  neuroglia  sclerosis  or  a  gliosis.  Secondary  scleroses 
are  those  which  are  the  result  of  inflammations,  hemorrhages, 
injuries,  embolism,  and  thrombosis.  A  secondary  sclerosis  usu- 
ally affects  certain  special  areas  of  the  brain  and  is  called  a  lobar 
sclerosis.  Corresponding  to  these  pathological  changes  we  have 
certain  clinical  types  of  disease.  Thus  the  diffuse  cortical  scle- 
roses cause  what  is  known  as  paralytic  dementia ;  polioencephali- 
tis superior  and  inferior  cause  bulbar  paralysis  and  ophthalmo- 
plegia; neuroglia  sclerosis  is  perhaps  at  the  basis  of  epilepsy  and 
other  degenerative  disorders ;  lobar  sclerosis  is  the  lesion  in  cases 
of  cerebral  palsies  of  children,  such  as  hemiplegias,  diplegias,  and 
paraplegias,  and  many  forms  of  inco-ordination,  motor  disturb- 
ance, and  convulsive  manifestations. 

Besides  the  terms  that  we  have  used  here,  there  are  in  medi- 
cal literature  frequently  employed  the  expressions  brain  atrophy, 
hypertrophy,  porencephaly,  chronic  cerebritis,  tuberous  scle- 
rosis, all  of  which  terms  are  more  or  less  synonymous  with  what 
we  have  already  given  and  are  superfluous  to  our  nosology. 

There  is  possibly  a  primary  chronic  softening  or  degeneration 
of  the  brain,  but  if  it  exists  is  extremely  rare,  and  occurring  in 
advanced  life  is  probably  due  to  disturbances  in  the  blood  sup- 
ply. 


374  DISEASES    OF   THE   NERVOUS   SYSTEM. 


MuiiTiPLE  Sclerosis  (Disseminated  Sclerosis,  Ixsular 
Sclerosis,  Sclerosis  ex  Plaques  Dissemixees). 

Multiple  sclerosis  is  a  chronic  degenerative  disease  character- 
ized by  the  development  of  small  patches  of  connective  tissue 
throughout  the  brain  and  spinal  cord,  and  by  symptoms  of  paral- 
ysis, tremor,  disturbances  of  speech  and  of  the  eye  muscles,  and 
by  a  number  of  other  symptoms,  very  variable  in  character. 

In  America  the  disease  is,  in  the  writer's  experience,  rare. 
The  diagnosis,  to  be  sure,  is  often  made,  but  only  two  cases  ver- 
ified by  post  mortems  have  been  reported  by  American  physi- 
cians. 

^^ioZo^^.— Heredity  is  a  predisposing  cause  in  a  small  propor- 
tion of  cases.  The  disease  has  been  directly  inherited;  but 
generally  the  patient  simply  inherits  a  neuropathic  constitution. 
The  disease  develops  in  the  early  part  of  adult  life,  oftenest  be- 
tween the  ages  of  thirty-five  and  forty-five,  but  it  maj'  occur  in 
children,  and  it  is  probable  that  a  considerable  number  of  cases 
developing  in  adult  life  are  cases  in  which  the  seeds  of  the  disease 
were  sown  during  adolesqence.  The  sexes  are  about  equally 
affected,  the  preponderance  being  rather  in  favor  of  the  female. 

The  chief  exciting  cause  of  most  cases  is  undoubtedly  some 
infective  fever,  usually  typhoid,  diphtheria,  small-pox,  measles, 
or  erysipelas.  It  has  been  known  to  follow  an  acute  attack  of 
hsemoglobinuria  and  perhaps  of  malaria.  Myelitis  and  encephali- 
tis are  said  to  have  led  to  the  subsequent  development  of  multi- 
IDle  sclerosis,  but  this  is  unlikely.  Exposure  to  cold  and  wet  and 
traumatisms,  especially  those  which  lead  to  the  development  of 
the  traumatic  neuroses  so  called,  are  sometimes  the  cause  of  the 
disease.  In  fine,  acute  infections  and  severe  traumatisms  involv- 
ing concussion,  co-operating  with  a  neuropathic  nervous  system, 
form  the  most  important  etiological  factors.  Syphilis  is  rarely  a 
cause. 

Symptoms. — The  disease  probably  has  existed  a  long  time  be- 
fore very  notable  sj'mptoms  develop.  Among  the  first  things 
which  the  patient  observes  is  a  weakness  in  the  limbs,  usually  in 
an  arm  or  leg ;  this  is  soon  accompanied  with  a  tremor  which  is 
of  a  jerky,  irregular  character.  The  paralysis  slowly  extends  and 
the  patient  becomes  partially  paraplegic  or  hemiplegic.  He  may 
have  some  ataxia  with  the  paralysis.  At  the  same  time  disturb- 
ances in  vision  occur,  such  as  amblyopia,  spots  before  the  eyes, 
nystagmus,  and  diplopia.  Defects  in  articulation  develop ;  the 
speech  becoming  slow  and  scanning,  or  "  syllabic,"  as  it  is  called. 
Attacks  of  vertigo  or  apoplectic  or  epileptic  seizures  occur. 
There  may  be  some  sensory  symptoms,  although  these  are  usu- 


DEGENERATIONS   AND   SCLEROSES.  375 

ally  not  marked  or  permanent.  When  present  they  consist  of 
pains  in  the  limbs,  resembling  those  of  locomotor  ataxia,  and 
anaesthesias  variously  distributed.  Mental  change  is  not  infre- 
quent and  is  somewhat  characteristic.  The  patient's  mind  is 
rather  dull,  but  his  temper  is  equable  and  placid.  The  memory 
may  become  weak ;  very  rarely  insanity  develops. 

The  disease  runs  a  very  variable  course,  depending  upon  the 
seat  of  the  multiple  lesions.  In  typical  forms  these  lesions  are 
distributed  throughout  the  brain  and  spinal  cord,  but  chiefly  in 
the  brain  axis,  and  consequently  in  these  cases  the  progress  of 
the  symptoms  is  fairly  uniform.  We  have  referred  to  them  in 
the  brief  outline  of  the  disease ;  they  may  be  enumerated  here 
again.  1st.  Paralysis  taking  the  form  of  hemiplegia,  paraplegia, 
monoplegia,  or  some  cranial  nerve  paralysis.  2d.  A.  jerky  tremor, 
often  called  intention  tremor.  3d.  Spastic  phenomena  shown  by 
exaggeration  of  knee  jerks,  clonus,  and  rigidity  of  limbs.  4th. 
Cerebral  disturbances  characterized  by  vertigo,  headache,  epi- 
leptiform and  apoplectiform  attacks,  and  the  peculiar  mental 
state  referred  to.  5th.  Nystagmus  and  disorders  of  vision  and 
of  the  optic  nerve.  6th.  Disorders  of  articulation  or  scanning 
speech.  7th  and  finally,  an  irregular  and  intermittent  course  to 
the  disease. 

We  will  take  up  some  of  these  symptoms  now  in  detail.     The 
l^aralysis  is  most  frequently  of  the  nature  of  a  hemiplegia  or 
paraplegia  which  is  never  complete,  but  rather  in  the  shape  of  a 
simple  weakness.     This  paresis  is  almost  always  accompanied 
with  a  spastic  condition,  so  that  there  is  exaggeration  of  reflexes 
and  clonus.     It  is  often  also  accompanied  with  an  inco-ordination, 
but  most  frequently  of  all  it  is  associated  with  the  peculiar  "  in- 
tention tremor  "  referred  to.     This  tremor  is  coarse  in  its  charac- 
ter; it  ceases  when  the  limbs  are  at  rest  and  is  shown  only  when 
voluntary  movements  are  attempted.     Thus  when  the  patient 
tries  to  raise  a  glass  of   water  to  his  lips  the  jerky  trenmlous 
movements  increase  so  that  the  water  is  spilled  before  it  reaches 
his  mouth.     The  tremor  affects  the  muscles  of  the  neck  some- 
times, so  as  to  cause  oscillation  of  the  head ;  and  sometimes  the 
muscles  of  the  trunk,  but  rarely  if  ever  the  facial  muscles.     The 
nystagmus,  which  is  another  manifestation  of  the  tremor  of  the 
disease,  is  usually  lateral' and  is  present  in  about  two-thirds  of 
the  cases.     Eye  palsies  involving  most  often  the  sixth  nerve  occur 
in  about  one-sixth  of  the  cases.     The  pupillary  and  ciliary  mus- 
cles are  rarely  affected,  and  the  Argyll-Robertson  pupil  is  not 
found  in  the  disease.     The  disturbance  of  articulation  is  very 
common,  ranking  in  frequency  with  the  nystagmus  and  tremor. 
In  speaking  the  patient  separates  the  words  into  distinct  sylla- 
bles, or  he  may  simply  separate  the  words  very  distinctly  from 


376  DISEASES   OF  THE   NERVOUS   SYSTEM. 

each  other.  Sometimes  words  are  dropped  or  imperfectly  pro- 
nounced. The  trouble  seems  to  be  due  to  inco-ordinate  move- 
ments of  the  tongue  and  other  muscles  and  organs  concerned  in 
articulation.  The  cutaneous  disturbances  of  sensation  are  not 
very  great.  They  occur  in  perhaps  one-third  of  the  cases,  but 
are  often  temporary  and  are  perhaps  due  to  a  superimposed  hys- 
teria. Severe  pain  is  not  a  common  symptom,  but  it  may  exist 
in  the  form  of  neuralgias  of  the  nerves  of  the  limbs  or  in  the 
shape  of  girdle  pains.  The  anaesthesias  are  usually  partial  and 
involve  only  small  areas  of  the  limbs.  There  may  be  various 
parsesthesise  affecting  the  paralyzed  parts  of  the  body.  Of  the 
nerves  of  special  sense  the  eye  is  most  frequently  involved,  and  a 
study  of  its  condition  is  most  important.  The  paralyses  of  its 
muscles  and  consequent  diplopia  have  been  referred  to.  Tem- 
porary disturbance  of  vision  is  not  uncommon.  Such  disturb- 
ances consist  of  constriction  of  the  visual  field,  amblyopia,  and 
scintillating  scotomata.  The  fundus  of  the  eye  shows  in  some 
cases  a  slight  degree  of  neuritis,  and  in  the  later  stages  a  true 
atrophy  may  be  present.  One  eye  is  usually  more  involved  than 
the  other,  and  one  eye  alone  may  be  affected.  The  oi^hthalmo- 
scopic  changes  in  the  disc  are  said  to  be  different  from  those 
found  in  locomotor  ataxia  and  in  the  neuritis  of  brain  tumors. 

Disorders  of  the  visceral  centres  producing  retention  of  urine, 
constipation,  and  trophic  disturbances  leading  to  oedema,  skin 
eruption,  arthritis,  etc.,  are  relatively  rare  and  occur,  if  at  all,  in 
later  stages  of  the  disease. 

Aborted  Types  or  "  Forms  frustes  "'  of  Multiple  Scle- 
rosis.— In  some  cases  the  nodules  of  sclerosis  are  so  limited  in 
number  and  so  peculiarly  jilaced  that  they  give  rise  to  very 
atypical  fonns  of  the  disease.  Perhaps  the  most  common  one  is 
that  in  which  the  disease  takes  the  type  of  a  progressive  spastic 
paraplegia.  The  pati  nt  suffers  from  weakness  of  the  lower 
limbs,  accompanied  with  stiffness,  cramps,  exaggerated  reflexes, 
and  disturbances  in  the  bladder  and  rectal  functions.  Anaes- 
thesias, pains,  and  the  girdle  symptom  may  develop.  In  addition 
to  this,  however,  a  close  examination  will  show  some  evidence  of 
disease  of  the  optic  nerves  and  perhaps  disturbances  of  the  eye 
muscles.  The  patient  will  have  nystagmus,  diplopia,  or  other 
visual  disorders.  There  will  also  be  some  attacks  of  vertigo  or 
of  epileptoid  convulsions.  The  combination  of  the  eye  symptoms 
with  the  progressive  paraplegia  will  often  reveal  the  true  char- 
acter of  the  disease. 

A  purely  sjnnal  form  of  multiple  sclerosis  has  been  described; 
it  is  probable,  however,  that  multiple  sclerosis  never  affects  the 
spinal  cord  alone.  A  cerebral  form  of  multiple  sclerosis  has  also 
been  described,  but  this  usually  runs  a  course  very  similar  to 


DEGENERATIONS   AND   SCLEROSES. 


377 


that  of  the  true  cerebro-spinal  malady,  and  it  is  unwise  to  at- 
tempt to  make  any  special  clinical  distinction,  Charcot  divides 
the  symptoms  into  cerebral  and  sj)inal,  and  includes  under  the 
cerebral  the  eye  symptoms,  apoplectic  attacks,  and  speech  dis- 
turbances; under  the  spinal  symptoms,  paralysis  and  tremor. 
Tremor,  however,  is  often,  if  not  usually,  due  to  a  cerebral  lesion. 
Pathology. — Grayish  nodules  are  found  distributed  through 
the  brain  and  spinal  cord.  They  vary  in  size  from  a  millimetre 
to  two  or  three  centimetres  in  diameter  (one- twenty-fifth  to  one 


Fig.  184.  Fig.  185. 

Figs.  184  and  185.— Multiple  Cerebro-Spinal  Sclerosis  (Charcot). 


inch).  They  are  of  firmer  consistence  than  the  surrounding  brain 
substance,  but  are  not  quite  so  hard  as  ordinary  connective  tissue. 
They  consist  microscopically  of  fibrous  tissue  which  does  not 
seem  to  be  connected  with  the  walls  of  the  blood-vessels  as  a  rule. 
Very  often  the  axis  cylinders  of  nerves  can  be  seen  passing  through 
the  lesion.  The  nodules  are  found  most  frequently  in  the  white 
matter  of  the  brain,  more  especially  in  the  pons,  internal  capsule, 
and  centrum  ovale  (Figs.  184,  185).  They  rarely  begin  primarily 
in  the  gray  matter,  but  may  invade  it  secondarily.  The  roots  of 
the  peripheral,  especially  of  the  cranial,  nerves  occasionally  con- 


378  DISEASES   OF   THE  NERVOUS  SYSTEM. 

tain  or  are  surrounded  by  these  sclerotic  masses.  In  the  spinal 
cord  they  may  extend  up  and  down  the  gray  and  white  matter  for 
a  considerable  distance,  or  they  may  involve  the  whole  cord  at  a 
certain  level,  turning  it  into  a  fibrous  mass.  The  blood-vessels  sur- 
rounding and  in  connection  with  these  diseased  areas  show  some 
evidences  of  thickening  and  increased  vascularity,  but  no  true 
inflammatory  process.  The  primary  pathological  change  in  mul- 
tiple sclerosis  is  as  yet  unknown  ;  many  things  point  to  its  start- 
ing originally  from  small  emboli  or  thrombi  which  lead  to  minute 
softenings,  with  a  secondary  reparative  and  sclerotic  process. 
The  fact  that  the  disease  follows  infective  fevers  makes  such  an 
origin  of  it  seem  probable.  On  the  other  hand,  pathological 
anatomy  does  not  yet  bear  out  this  view,  and  it  is  possible  that 


m^.^^Wf^  ••" 


Fig.  186.— Spinal  Sclerosis,    J,  K,  L,  M,  Sclerotic  foci :   A.  anterior,  B,  posterior 

horn  (BIoccl)- 


the  disease  begins  by  a  primary  degeneration  affecting  first  the 
myelin  sheaths  of  the  nerve  fibres,  this  being  followed  by  a  neu- 
roglia and  connective-tissue  proliferation  which  ends  in  the 
formation  of  the  small  islands  of  sclerosis.  An  important  patho- 
logical peculiarity  of  the  process  is  that  while  it  destroys  the 
myelin  sheaths  of  the  nerves,  the  axis  cylinders  remain  intact  for 
a  long  time,  and  consequently  conduction  of  nerve  impulses 
takes  place  imperfectly,  directly  through  the  nodular  masses. 

Course  and  Buratioii.— The  disease  runs  a  very  irregular 
course.  Its  prodromal  stage  is  long  and  remissions  of  consider- 
able length  occur.  The  disease  may  last  from  five  to  fifteen  years, 
the  average  duration  being  five  or  six  years.  Death  sometimes 
occurs  from  involvement  of  the  nerves  of  the  medulla,  but 
more  often  from  weakness  and  exhaustion  or  some  intercurrent 
malady. 


DEGENERATIONS   AND   SCLEROSES.  379 

Diagnosis.— The  diagnosis  in  typical  cases  is  not  very  difficult ; 
but  as,  on  the  other  hand,  typical  cases  are  not  common,  the 
disease  has  always  to  be  studied  with  great  care  before  certainty 
can  be  reached.  The  diagnosis  is  based  upon  the  slow  develop- 
ment of  the  disease,  with  attacks  of  vertigo,  weakness,  and  un- 
certainty in  gait;  upon  the  paralysis  of  the  extremities  with 
intention  tremor,  ataxia,  rigidity,  and  contractures;  upon  the 
disturbances  of  vision,  nystagmus,  and  the  speech  troubles.  The 
presence  of  headache,  attacks  of  vertigo,  apoplectiform  attacks, 
and  the  peculiar  mental  condition  often  furnish  help.  The  age 
of  the  patient  and  the  cause  should  also  be  taken  into  consider- 
ation. The  disease  must  be  distinguished  from  Friedreich's 
ataxia,  spastic  spinal  paralysis,  locomotor  ataxia,  dementia  para- 
lytica, bulbar  paralysis,  paralysis  agitans,  chronic  meningitis, 
and  hysteria.  The  points  already  given  and  those  furnished 
under  the  heads  of  these  different  diseases  must  be  utilized  in 
making  these  distinctions.  The  method  of  exclusion  may  be  used 
with  advantage  in  reaching  the  diagnosis  of  this  protean  malady. 

Prognosis. — The  prognosis,  while  not  favorable  as  regards  the 
ultimate  cure,  is  somewhat  favorable  as  regards  the  remission 
and  improvement,  and  the  disease  on  the  whole  is  not  so  severe 
as  is  locomotor  ataxia  or  the  other  degenerative  disorders. 

Treatment.— In  the  treatment  the  same  measures  recom- 
mended for  other  degenerative  diseases  of  the  nervous  system 
must  be  employed.  Hygienic  aieasures,  electricity,  and  hydro- 
therapy have  some  therapeutic  value.  Internally  the  use  of 
large  doses  of  iodide  of  potassium,  the  hypodermic  injection  of 
arsenic,  the  administration  of  nitrate  of  silver  and  of  quinine 
and  other  tonics  are  advised.  A  very  regular,  systematic,  and 
quiet  mode  of  life,  combined  with  the  use  of  iodide  of  potassium 
and  bichloride  of  mercury,  has  produced  the  best  results  in  my 
experience,  even  in  cases  which  gave  no  history  of  syphilitic  in- 
fection. 

Hypertrophy  and  Atrophy  of  the  Brain. 

These  are  both  terms  which  can  be  dropped  from  neurological 
nomenclature  as  representing  distinct  disorders.  Hypertrophy 
of  the  brain  has  been  described  as  a  disease  occurrmg  m  child- 
hood, developing  either  congenitally  or  in  association  with  rick- 
ets. It  has  been  said  to  produce  much  the  same  symptoms  ob- 
jectively as  hydrocephalus.  There  is  not  sufficient  pathological 
evidence  to  justify  us  in  saying  that  the  hypertrophy  is  really  a 
hypertrophy  of  the  brain,  rather  than  a  chronic  inflammation  or 
gliomatosis  or  some  other  tumor  formation. 

Atrophy  of  the  brain  may  be  either  total  or  partial.  When 
total,  that  is,  involving  the  whole  of  the  encephalon,  it  is  con- 
genital and  is  described  under  the  term  microcephaly.     A  slight 


380  DISEASES  OF  THE  NERVOUS  SYSTEM. 

decree  of  general  atrophy  occurs  during  senility  and  in  the  later 
stages  of  chronic  insanity.  Partial  brain  atrophy  is  either  con- 
genital or  acquired.  When  congenital  it  is  due  to  some  intra- 
uterine inflammation,  vascular  obstruction,  or  aphasia ;  and  when 
acquired  it  is  due  to  some  of  the  numerous  causes  which  have 
been  described  under  the  head  of  infantile  and  birth  palsies.  It 
will  be  seen  that  brain  atrophy  does  not  have  any  place  as  a 
distinct  disease. 


CHAPTER  XX. 

TUMORS   OF  THE  BRAIN.-SYPHILIS. 

The  kinds  of  tumor  found  in  the  brain  are  tubercle,  syph- 
iloma, glioma,  and  sarcoma,  which  are  the  common  forms; 
myxoma,  carcinoma,  fibroma,  osteoma,  cholesteatoma,  lipoma, 
psammoma,  neuroma,  vascular  tumors  including  aneurisms, 
echinococcus,  and  cysticercus.  In  fact,  all  forms  of  new  growths 
are  found  in  the  brain ;  but  the  infectious  granulomata,  tubercle, 
and  gumma  and  the  sarcomatous  type  of  tumors  are  the  most 
common.  As  compared  with  other  organic  diseases  of  the  cen- 
tral nervous  system,  brain  tumors  are  rare. 

Etiology. — Brain  tumors  affect  males  oftener  than  females,  the 
ratio  being  about  as  two  to  one  (644 :  320).  Sarcomata  alone  seem 
to  affect  females  about  as  often  as  males.  Brain  tumors  occur 
with  about  equal  frequency  throughout  all  ages  of  life  up  to 
about  fifty ;  one-third  occur  under  the  age  of  twenty  (Gowers). 
During  childhood  tumors  are  about  equally  distributed  through- 
out all  ages  (Starr).  One-half  of  all  the  tumors  of  childhood  are 
tubercular;  after  this  come  gliomata  and  sarcomata.  The 
gumma,  glioma,  and  sarcoma  begin  to  be  more  frequent  after  the 
age  of  twenty.  Sarcoma  and  especially  cancer  occur  in  the  mid- 
dle and  later  ages  of  life;  but  brain  tumors  of  any  kind  are  ex- 
tremely rare  after  the  age  of  sixty. 

To  sum  up  in  tabular  form,  the  relative  frequency  of  the  dif- 
ferent kinds  of  tumors  with  regard  to  age  is  shown  in  the  follow- 
ing: 

Childhood,       ....  tubercle,  parasites. 

Early  life,         ....  gumma,  glioma,  parasites. 

Early  and  middle  life,    .        .  sarcoma,  glioma,  and  gumma. 

Middle  and  late  life,        .        .  sarcoma,  gumma,  cancer. 

Heredity  has  a  slight  influence  in  predisposing  to  brain 
tumors.  Blows  on  the  head  and  other  forms  of  injury  to  the 
cranium  are  exciting  causes  in  a  small  proportion  of  cases. 

fSymptoms.— The  symptoms  of  brain  tumors  vary  extremely 
in  accordance  with  the  location,  the  kind  of  tumor,  the  rapidity 
of  growth,  and  the  age  of  the  patient.     The  general  course  of  a 


382  DISEASES   OF  THE   NERVOUS   SYSTEM. 

case  of  brain  tumor  in  an  adult  is  somewhat  as  follo\vs  The 
patient  first  notices  a  headache  which  is  very  intense  and  persist- 
ent and  which  has  exacerbations  of  frightful  severity.  With  the 
headache  or  between  the  attacks  vomiting  occurs,  which  is  often 
not  accompanied  with  any  nausea.  Sensations  of  vertigo,  an- 
noying parsesthesise,  and  convulsive  movements  affecting  one  or 
more  extremities  develop,  and  there  may  even  be  general  con- 
vulsions. The  patient  finds  that  his  eyesight  is  weak  and  pro- 
gressively deteriorates.  The  mind  becomes  more  or  less  dis- 
turbed, the  mental  processes  are  dull  and  slow,  a  feeling  of 
hebetude  and  incapacity  to  attempt  any  mental  exertion  is 
present.  As  the  disease  progresses  the  intense  pains  and  vomit- 
ing produce  weakness  and  emaciation.  Paralyses  of  various 
kinds  develop.  Blindness  may  ensue.  Convulsions  of  a  local  or 
general  character  become  more  frequent,  and  finally  the  patient 
becomes  bed-ridden  and  helpless. 

The  course  of  the  disease  is  not  a  steady  one,  there  being  often 
slight  remissions,  or  there  may  be  periods  when  progress  seems  to 
be  arrested.  After  a  period  of  time  varying  from  one  to  four  or 
five  years  death  occurs  from  exhaustion  or  some  intercurrent 
malady. 

The  symptoms  thus  very  briefly  outlined  are  divided  into  gen- 
eral and  focal.  The  general  symptoms  are  at  first  those  of  cere- 
bral irritation  and  of  headache,  vertigo,  and  vomiting,  optic  neu- 
ritis, convulsions,  disturbances  of  speech,  and  hebetude.  Head- 
ache occurs  in  from  one-half  to  two-thirds  of  the  cases ;  it  is  very 
severe  and  the  pains  are  of  a  bo.'ing  or  lancinating  character ; 
they  are  so  horrible  that  they  often  lead  the  patient  to  think  of 
suicide.  The  pains  are  sometimes  periodical,  occurring  every 
night  or  every  other  day,  and  suggest  by  their  periodicity  a  mala- 
rial character.  They  are  located  sometimes  in  the  brow  or  in 
the  occiput,  while  sometimes  they  are  diffused  all  over  the  head ; 
they  are  rather  more  frequent  than  otherwise  in  the  neighbor- 
hood of  the  tumor.  They  are  more  frequent  with  cerebellar 
tumors  than  with  those  located  anywhere  else.  They  are  also 
frequent  with  tumors  of  the  mid-brain  and  of  the  cerebral  hemi- 
spheres. They  are  less  frequent  when  situated  in  the  peduncles 
and  at  the  base  of  the  brain.  The' pains  are  due  to  the  increased 
intracranial  pressure  and  to  irritation  of  the  membranes  of  the 
brain  by  the  encroachment  upon  them  of  the  new  growth.  Head- 
ache occurs  in  about  the  same  proportion  in  children  and  adults, 
and  it  does  not  seem  to  bear  much  relation  to  the  kind  of  tumor, 
although  the  pains  are  generally  less  with  the  gliomata,  and  they 
are  more  frequent  with  rapidly  growing  tumors  whatever  their 
character.  With  the  pains  there  is  often  a  local  tenderness  of 
the  scalp  and  cranium  which  may  be  elicited  by  percussion,  and 


TUMORS   OF  THE   BRAIN.  383 

in  most  cases  there  is  greater  tenderness  in  that  part  of  the  cra- 
nium lying  over  the  tumor. 

Vomiting  is  a  symptom  which  is  ahnost  as  frequent  as  head- 
ache. The  vomiting  is  often  of  a  projectile  character  and  not 
accompanied  with  much  nausea.  Vomiting  occurs,  as  does 
headache,  more  frequently  with  cerebellar  tumors.  It  is  asso- 
ciated with  rapidly  growing  tumors  such  as  syphilitic  or  tuber- 
cular neoplasms.  Vertigo  is  a  general  symptom  which  occurs 
in  from  one-third  to  one-half  of  the  cases.  The  vertigo  may  be 
slight,  such  as  is  often  felt  from  ordinary  causes.  Occasionally 
it  is  very  severe  and  accompanied  with  forced  movements. 
The  severer  forms  and  those  associated  with  forced  movements 
occur  with  tumors  of  the  cerebellum  and  the  parts  closely  con- 
nected with  it.  Optic  neuritis  is  one  of  the  most  frequent  and 
important  of  all  the  general  symptoms  of  brain  tumor;  it  occurs 
at  some  period  of  the  disease  in  at  least  four-fifths  of  the  cases, 
more  frequently  in  cerebellar  tumors  and  in  those  of  the  mid- 
brain and  great  basal  ganglia.  It  is  rare  in  tumors  of  the  me- 
dulla. It  is  less  frequent  and  marked  in  the  slow-growing 
tumors.  The  neuritis  may  run  a  somewhat  rapid  course  and  then 
improve  a  great  deal  or  even  for  a  time  disappear;  but  ordinarily 
the  course  is  progressive  and  it  ends  eventually  in  an  atrophy  of 
the  optic  nerve.  Hence  the  examination  of  the  eyes  in  brain 
tumors  should  be  made  a  number  of  times  in  order  to  note  the 
progress  of  the  trouble.  Primary  atrophy  of  the  optic  nerve 
does  not  occur  in  brain  tumors.  The  inflammation  almost  al- 
ways affects  both  nerves,  but  it  may  begin  with  one  and  subse- 
quently affect  the  other.  The  cause  of  optic  neuritis  in  brain 
tumors  has  been  the  subject  of  a  great  deal  of  discussion  and 
theorizing.  There  are  doubtless  different  factors  entering  into 
the  mechanism  of  its  production  in  different  cases,  but  accepting 
the  modern  doctrines  of  inflammation,  we  must  believe  that  the 
most  probable  and  most  essential  cause  is  an  irritation  of  the 
nerve  fibres  by  the  products  of  the  growth  of  the  tumor  which 
infiltrate  into  the  sheaths  of  the  optic  nerves.  There  are  pecul- 
iar mechanical  conditions  which  tend  to  hold  these  products 
within  the  sheaths  and  thus  enable  them  to  act  more  energet- 
ically as  irritants.  Simple  mechanical  processes  alone— the  ten- 
sion and  pressure— would  hardly  explain  the  presence  of  a  genu- 
ine inflammation. 

Mental  defects  are  almost  always  present  in  tumors  of  the 
brain.  These  defects  consist  in  a  slowness  of  the  mental  pro- 
cesses, a  condition  of  hebetude,  a  tendency  to  attacks  of  somno- 
lence, and  sometimes  a  peculiar  childishness  and  silliness  or  pecul- 
iar mental  irritability.  The  memory  is  also  usually  someAvhat 
weakened  and  the  power  of  attention  lessened.     Such  psychical 


3S4  DISEASES   OF   THE   NERVOUS   SYSTEM. 

defects  are  more  frequent  with  tumors  of  the  fore-brain  and 
more  frequent  also  witli  large  tumors.  General  convulsions  occur 
in  about  one-fourth  of  the  cases  and  more  frequently  when  the 
tumors  are  situated  in  the  cerebral  hemispheres  and  cortex. 
There  may  be  also  apoplectiform  attacks,  from  which  the  patient 
recovers  in  the  course  of  a  few  days  or  weeks.  More  rarely  there 
is  a  genuine  apoplexy  from  the  bursting  of  a  blood-vessel  in  the 
neighborhood  of  the  tumor. 

The  speech  disturbances  are  most  marked  in  tumors  which 
affect  the  pons  and  medulla  and  the  origin  of  the  cranial  nerves. 
Such  siDcech  disturbances,  when  characteristic,  are  shown  by  a 
confluent  articulation,  that  is  to  say,  the  patient  runs  the  sylla- 
bles together. 

The  cranial  temperature  in  brain  tumors  is  in  most  cases 
somewhat  raised  as  compared  with  the  normal  (Gray,  Mills,  and 
Lloyd).  The  elevation  may  be  several  degrees  above  the  normal. 
The  normal  average  scalj)  temperatures  (Gray)  are  from  92^  to 
94.5°  F.,  being  somewhat  higher  over  the  frontal  and  parietal  than 
over  the  occipital  regions.  In  brain  tumors  the  temperature  has 
been  found  raised  to  95°,  96°,  and  98".  The  value  of  thermometric 
observations,  however,  in  the  symptomatology  of  brain  tumors  is 
somewhat  doubtful,  owing  to  the  variability  in  the  normal  tem- 
perature and  the  difficulty  of  getting  accurate  records. 

Focal  Symptoms. — The  symptoms  of  brain  tumor  are  pro- 
duced in  part  by  the  irritation  and  pressure,  in  part  by  destruc- 
tion of  the  normal  tissues.  The  sjauptoms  are  also  modified  by 
variations  in  the  vascularity  of  the  tumors,  and  perhaps  to  some 
extent  by  direct  irritation  from  products  secreted  by  the  tumor 
cells.  Having  by  a  study  of  general  symptoms  arrived  at  a  fairly 
certain  diagnosis  as  to  the  presence  of  a  tumor,  it  is  necessary  to 
corroborate  the  diagnosis  and  to  localize  the  lesion  by  an  exam- 
ination of  the  symptoms  which  are  the  result  of  irritation  or 
destruction  of  certain  particular  parts  of  the  brain;  these  are 
called  the  focal  symptoms.  For  purposes  of  special  or  local  diag- 
nosis we  divide  the  brain  into  the  following  parts  or  areas  (Knapp) : 
1.  The  prsefrontal,  which  includes  all  that  part  lying  in  front  of  a 
line  that  extends  fj'om  the  upper  end  of  the  ascending  branch  of 
the  fissure  of  Sylvius  directly  up  at  right  angles  to  a  horizontal 
line  between  the  frontal  and  occipital  poles  of  the  brain  (see 
Fig.  187).  This  region  includes  probably  centres  for  the  move- 
ment of  the  head  and  eyes,  but  it  is  chiefly  concerned  with  the 
higher  intellectual  processes ;  its  under  surface  lies  on  the  orbital 
plate  of  the  frontal  bone  and  upoh  the  right  olfactory  lobes.  2. 
The  central  region,  which  is  bounded  in  front  by  the  vertical 
line  just  described,  behind  by  a  line  passing  down  from  the  an- 
terior end  of  the  parietal  fissure  to  the  fissure  of  Sylvius,  and 


TUMORS   OF   THE   BRAIN. 


385 


above  by  a  line  that  bounds  posteriorly  the  post-central  convo- 
lution. 3.  The  parietal  lobe.  4.  The  occipital  lobe.  5.  The  tem- 
poral or  temporo-sphenoidal  area.  G.  The  corpus  callosum.  7. 
The  great  basal  ganglia  and  capsules.  8.  The  corpora  quadri- 
gemina,  deep  marrow,  and  pineal  gland.  9.  The  crura  cerebri. 
10.  The  pons  and  medulla.     11.  The  cerebellum.     12.  The  basal 


surface  of  the  brain.  The  boundaries  of  most  of  these  areas 
are  indicated  better  by  the  figure  than  by  a  description.  They 
correspond  to  some  extent  with  the  cerebral  lobes,  but  not  en- 
tirely so,  since  the  frontal  and  parietal  lobe  divide  between  them 
the  central  area. 

1.  Tumors  of  the  prefrontal  area.     Tumors  in  this  area  often 
show  no  particular  localizing  symptoms,  and  this  part  of  the  brain 
25 


386  DISEASES   OF   THE   NERVOUS   SYSTEM. 

is  consequently  put  down  as  a  latent  one ;  nevertheless,  in  a  grood 
proportion  of  cases  tumors  here  produce  peculiar  mental  disturb- 
ances that,  taken  in  conjunction  with  the  general  symptoms, 
enable  us  to  make  a  local  diagnosis.  The  symptoms  are  pecul- 
iar mental  hebetude,  childishness,  irritability,  often  a  kind  of, 
silliness  and  emotional  weakx^ess,  a  tendency  to  laugh  and  cry 
and  to  get  angry  at  trifling  causes.  The  entire  character  and 
temperament  of  the  man  are  sometimes  changed.  Besides  this, 
owing  to  implication  of  the  olfactory  nerve,  there  may  be  loss  of 
the  sense  of  smell  on  one  or  both  sides ;  implication  of  the  optic 
nerves  will  cause  hemianopsia  and  optic  neuritis.  If  the  tumor 
involves  the  orbit  there  will  be  paralyses  of  the  ocular  muscles 
and  protrusion  of  the  globe  of  the  eye.  If  the  tumor  grows  back- 
ward there  is  gradual  invasion  of  motor  centres  with  irritation, 
showing  itself  by  spasms,  convulsions,  and  later  by  paralyses. 

2.  Tumors  of  the  central  region.  It  is  in  this  area  that  we  are 
often  able  to  make  the  closest  and  most  accurate  diagnosis  of  the 
localization  of  new  growths,  owing  to  their  involvement  of  the 
different  motor  centres.  Through  this  involvement  these  centres 
are  at  first  irritated,  with  the  result  of  producing  local  spasms  or 
Jacksonian  epilepsy.  Such  spasms  are  often  preceded  by  sensory 
symiDtoms  or  aurse.  As  the  tumor  grows  the  area  of  involve- 
ment becomes  larger,  spasms  become  more  diffused,  and  general 
convulsions  may  finally  appear,  with  hemiplegia.  The  motor  dis- 
turbances are  not  infrequently  accompanied  with  sensory  dis- 
orders. These  may  be  simply  feelings  of  numbness  or  prickling 
which  either  are  permanent  or  simply  precede  spasms,  or  there 
may  be  hemiansesthesia  of  a  moderate  degree  to  pain,  touch, 
and  temperature.  The  muscular  sense  also  may  be  somewhat 
involved.  In  case  of  slight  sensory  involvement  the  capacity  for 
localizing  sensations  seems  to  be  most  implicated.  Besides  the 
symptoms  mentioned,  there  may  also  be  motor  aphasia  and 
agraphia.  The  exact  localization  must  be  worked  out  with  the 
help  of  the  figures  and  descriptions  given  under  anatomy. 

3.  Tumors  of  the  parietal  area.  The  symptoms  pi-oduced  by 
tumors  m  this  area  may  be  very  slight.  The  most  characteristic 
are  disturbances  of  muscular  sense  which  occur  when  the  supra- 
marginal  gyrus  is  affected,  and  word  blindness  Avhich  occurs 
when  the  angular  gyrus  and  inferior  lobule  are  affected.  When 
the  tumor  is  higher  up  near  the  longitudinal  fissure,  the  muscles 
of  the  lower  limbs  may  be  involved,  and  if  the  tumor  encroaches 
upon  the  central  area  spasms  and  paralyses  of  various  muscular 
groups  ensue.  The  cortical  representation  of  the  third  nerve  is 
thought  to  be  in  the  neighborhood  of  the  angular  gyrus,  and 
some  cases  have  been  reported  in  which  paralysis  of  this  nerve 
resulted  from  tumors  in  that  area. 


TUMORS   OF  THE   BRAIN.  387 

4.  Occipital  lobes.  Tumors  in  this  region,  if  situated  in  the 
cuneus  and  first  occipital  convolution,  produce  homonymous 
hemianopsia.  If  the  tumor  involves  the  other  parts  of  the  occi- 
jpital  lobe  and  the  cuneus  is  not  seriously  involved,  there  may  be 
a  condition  known  as  soul  blindness  or  incapacity  to  understand 
the  nature  of  the  things  which  one  sees.  If  the  tumor  extends 
up  chiefly  toward  the  angular  gyrus,  there  may  be  word  blind- 
ness, along  with  some  hemianopsia.  If  the  tumor  extends  farther 
forward  into  the  parietal  lobe,  there  may  be  hemiansesthesia, 
hemiataxia,  and  perhaps  a  little  hemiplegia  owing  to  involvement 
of  the  fibres  of  the  internal  capsule. 

5.  Temporal  area.  The  temporal  or  temporo-sphenoidal  area 
on  the  right  side  is  very  nearly  a  latent  one.  On  the  left  side 
tumors  involving  the  posterior  part  of  the  first  and  upper  poste- 
rior part  of  the  second  temporal  convolution  produce  word  deaf- 
ness. Tumors  in  either  lobe  when  large  and  extending  well 
down  toward  the  base  may  produce  attacks  of  vertigo  or  forced 
movements,  owing  probably  to  irritation  of  the  internal  ear. 
Tumors  that  involve  the  hippocampal  convolution  and  the  uncus 
may  produce  perhaps  some  disturbances  in  the  senses  of  smell 
and  taste. 

6.  Tumors  of  the  corpus  callosum.  Tumors  situated  in  this 
area  are  very  rare.  Their  symptoms  have  been  thought  to  be 
somewhat  characteristic ;  but  in  the  writer's  experience  they  cor- 
respond closely  with  tumors  situated  in  the  third  ventricle  and 
lateral  ventricles  of  the  brain;  in  other  words,  tumors  which, 
beginning  in  the  central  parts  of  the  brain,  gradually  extend 
outward  toward  the  periphery.  The  symptoms  credited  to  tu- 
mors of  the  corpus  callosum  are,  first,  the  general  symptoms 
of  brain  tumor,  to  which  there  are  superadded  a  gradually  de- 
veloping hemiplegia  with  later  a  paraplegia.  At  the  same  time 
there  is  a  great  deal  of  mental  dulness,  stupidity,  and  drowsiness; 
the  patient  often  sits  for  hours  mute,  refusing  to  speak,  or  lies  in 
a  half-somnolent  condition.  There  are  no  paralyses  of  the  oculo- 
motor nerves  or  of  the  other  cranial  nerves.  There  is  no  anaes- 
thesia. The  disease  gradually  jDrogresses  and  the  patient  dies  in 
coma. 

7.  Tumors  of  the  great  basal  ganglia  and  the  capsule  (the 
optico-striate  region).  The  general  symptoms  of  tumors  of  this 
region  resemble  in  many  respects  those  of  tumors  of  the  corpus 
callosum.  The  stupidity,  however,  may  be  less  marked.  There 
is  usually  a  progressive  hemiplegia  which  may  be  accompanied 
with  anaesthesia  and  sometimes  with  choreic  movements,  if  the 
tumor  involves  the  optic  thalamus  and  adjacent  part  of  the  cap- 
sule. Tumors  of  the  caudate  nucleus  alone  and  of  the  lenticular 
nucleus  alone  seem  to  give  rise  to  no  special  symptoms,  and  these 


388  DISEASES   OF   THE   NERVOUS   SYSTEM. 

regions  are  regarded  as  latent.  Tumors  of  the  anterior  three- 
fourths  of  the  optic  thalamus  alone  may  cause  no  sjieeial  symp- 
toms, but  in  some  cases  there  occur  peculiar  choreic  or  athetoid 
movements.  Tliese,  however,  are  probably  due  to  irritation  of 
the  fibres  of  the  internal  capsule.  If  the  tumor  involves  the 
posterior  part  of  the  optic  thalamus  and  adjacent  areas,  there 
will  be  a  hemianopsia,  which  may  be  distinguished  from  the 
hemianopsia  due  to  lesions  in  the  occipital  lobe  by  the  presence 
of  the  hemiopic  pupillary  reaction,  that  is  to  say,  a  ray  of  light 
thrown  in  upon  the  insensitive  part  of  the  retina  will  not  pro- 
duce a  reflex  contraction  of  the  pu^Dil. 

8.  Tumors  of  the  corpora  quadrigemina,  deep  marrow,  and 
pineal  gland.  The  characteristic  symptoms,  as  shown  by  ]N"oth- 
nagel,  of  tumors  of  this  region  are  inco-ordination,  forced  move- 
ments, and  oculo-motor  palsies.  Together  with  these  there  may 
be  hemianopsia  or  blindness  due  to  destruction  of  the  primary 
optic  centres.  It  is  possible  that  some  degree  of  deafness  or 
hemi-deafness  may  be  produced  by  the  involvement  of  the  pos- 
terior tubercles  of  the  corpora  quadrigemina. 

9.  Tumors  of  the  crus.  Tumors  of  the  crura  cerebri  are  ex- 
tremely rare.  When  present,  they  cause  hemiplegia  and  i^er- 
haps  a  hemianaesthesia,  with  paralysis  of  the  third  nerve  upon 
the  same  side  as  the  lesion ;  in  other  words,  a  crossed  paralysis. 

10.  Tumors  of  the  pons  and  medulla.  Tumors  in  this  area 
necessarily  produce  very  varying  symptoms  in  accordance  with 
their  size  and  location.  If  the  tumor  is  in  the  pons  it  will  cause, 
if  situated  high  up,  a  palsy  of  the  third  nerve  upon  one  side  and 
hemiplegia  on  the  opposite  side.  If  lower  down  there  may  be  a 
palsy  of  the  fifth  nerve  on  one  side  and  hemiplegia  on  the  other 
side.  If  the  tumor  is  extensive  it  may  pi'oduce  not  only  a  hemi- 
plegia, but  a  hemianaesthesia.  If  situated  somewhat  superficially 
and  on  the  lateral  edge  of  the  pons  involving  the  peduncles,  there 
will  be  forced  movements  of  the  body,  either  toward  or  from  the 
seat  of  the  lesion.  If  the  tumor  is  in  the  medulla  it  will  produce 
hemiplegia  and  hemianaesthesia,  with  paralysis  of  the  hypoglossal 
nerve  or  perhaps  some  other  cranial  nerves  upon  the  same  side. 
If  large  and  involving  both  sides  of  the  medulla,  there  may  be 
the  general  symptoms  of  a  progressive  bulbar  paralysis.  One 
peculiarity  of  tumors  situated  in  the  pons  is  that  they  some- 
times produce  a  conjugate  deviation  of  the  eyes  which  is  away 
from  the  side  of  the  lesion.  In  this  respect  the  symptoms  differ 
from  conjugate  deviation  produced  by  lesion  in  the  cerebral 
hemispheres  where  the  head  and  eyes  are  turned  toward  the  side 
of  the  lesion. 

11.  The  general  symptoms  of  tumors  of  the  cerebellum  are,  as 
we  have  already  said,  more  pronounced  than  those  of  tumors  of 


TUMORS   OF   THE   BRAIN.  389 

other  regions;  we  more  frequently  have  headache,  vomiting,  ver- 
tigo, and  optic  neuritis  from  neoplasms  here.  If  the  tumor  is 
situated  in  the  lateral  lobes  of  the  cerebellum,  no  localizing 
symptoms  develop  until  the  tumor  becomes  very  large  so  that  it 
presses  ujion  the  medulla  or  other  adjacent  regions.  When  the 
tumor  is  m  the  middle  lobe  a  peculiar  ataxia  develops,  known  as 
cerebellar  ataxia.  The  gait  of  the  jDatient  is  a  reeling  one  like 
that  of  a  drunken  man,  or  in  Avalking  he  takes  short  steps  and 
spreads  his  legs  as  if  in  fear  of  falling.  This  has  been  called  the 
titubating  gait.  Besides  this,  severe  forced  movements  may  occur 
which  usually  throw  him  sideways  or  perhaps  forward,  very 
rarely  backward.  Secondary  symptoms  from  pressure  on  the 
medulla  often  develop  in  tumors  of  the  middle  lobe;  such  symp- 
toms being  glycosuria  and  disturbance  of  the  functions  of  the 
cranial  nerves.  Late  in  the  disease  hemiplegia  and  paraplegia 
and  bulbar  symptoms  may  develop  from  extreme  pressure. 
There  may  be  also  hydrocephalus  due  to  pressure  on  the  veins  of 
Gralen  and  obstruction  of  the  return  flow  of  blood  from  the  cen- 
tral arteries  of  the  brain. 

12.  Tumors  of  the  base  of  the  brain.  Tumors  situated  in  the 
anterior  fossa  produce  symptoms  very  much  like  those  described 
under  the  head  of  tumors  of  the  j^raefrontal  area,  but  there  is 
necessarily  destruction  of  the  olfactory  lobe  and  there  is  more  apt 
to  be  involvement  of  the  optic  and  oculo-motor  nerves  and  of  the 
tissues  of  the  orbit. 

Tumors  of  the  middle  fossa.  Tumors  sometimes  involve  the 
hypophysis.  Such  condition  has  been  found  in  cases  of  acro- 
megaly, and  it  has  been  suggested  that  the  tumor  of  the  hypo- 
physis is  the  cause  of  the  disease  referred  to ;  but  such  cannot  be 
the  case,  since  a  number  of  tumors  of  this  region  have  been  de- 
scribed in  which  none  of  the  symptoms  of  acromegaly  were  pres- 
ent. Tumors  of  this  region  and  of  the  interpeduncular  space 
produce  symptoms  such  as  would  naturally  result  from  pressure 
on  the  optic  chiasm,  and  it  is  mainly  the  early  presence  of  optic 
neuritis  and  of  peculiar  forms  of  hemianopsia  which  differentiates 
lesions  in  this  area  from  those  in  the  anterior  fossa. 

Multiple  tumors.  About  one-seventh  of  all  brain  tumors  are 
multiple.  Hence  in  making  a  diagnosis  of  the  localization  of 
tumors  this  fact  nmst  be  borne  in  mind.  The  tumors  which  are 
most  frequently  multiple  are  tubercle,  cancer,  and  melanotic 
growths. 

P«Y7?o/o^^//.— Tubercle  is  a  form  of  tumor  found  oftenest  in 
children  and  is  altogether  the  most  frequent  of  brain  tumors.  It 
is  more  often  located  in  the  cerebellum,  but  may  appear  in  the 
pons  or  other  parts  of  the  brain.  It  may  be  a  single  or,  as  it  is 
then  called,   a  solitary  tubercle,    or  there  may  be  a  multiple 


390  DISEASES   OF   THE   NERVOUS   SYSTEM. 

growth.  The  tumor  is  hregularly  round  in  shape  and  varies  in 
diameter  from  one  and  a  half  to  two  inches.  It  has  a  grayish- 
yellow  appearance  externally;  internally,  a  yellowish  or  cheesy 
look.  It  is  not  vascular,  but  is  often  surrounded  by  softened  or 
inflamed  tissue.  There  may  be  an  associated  meningitis.  The 
tumors,  when  solitary,  usually  start  from  the  central  parts  of  the 
brain,  but  they  also  develop  on  the  meninges  of  the  convexity, 
particularly  in  the  parietal  region,  and  sometimes  they  develop 
also  at  the  base.  Tubercle  always  arises  from  infection  by  the 
tubercle  bacilli  which  are  carried  by  the  blood  to  the  brain. 
The  tumors  develop  usually  from  some  infectious  focus,  starting 
in  a  blood-vessel  of  the  pia  mater.  Microscopically  the  tumor 
shows  the  ordinary  appearances  of  tuberculous  growths.  It  con- 
tains in  its  periphery  many  round  cells,  nuclei,  and  giant  cells. 
In  the  centre  there  is  usually  an  amorphous  substance,  the  prod- 
uct of  degeneration  and  the  breaking  down  of  the  ordinary  sub- 
stance of  the  tumor.  The  characteristics  of  the  growth  are  the 
presence  of  the  round  cells  and  giant  cells,  the  caseation  and  soft- 
ening of  the  centre,  and  the  absence  of  vascularization,  with  the 
presence  of  the  bacilli. 

Syphiloma  or  gumma.  'Gummatous  tumors  of  the  brain  are 
usually  associated  with  syphilitic  meningitis  or  some  other  form 
of  cerebral  syphilis  such  as  endarteritis  and  perhaps  inflammation 
of  the  cranial  nerve  roots.  Syphilitic  growths  are  usually  found 
upon  the  brain  surface,  oftenest  on  the  base,  next  upon  the  con- 
vexity of  the  frontal  and  central  convolutions.  The  process  ap. 
pears  either  in  the  form  of  a  somewdiat  distinct  tumor  or  in  the 
form  of  an  irregular  thickened  exudate  lying  upon  the  surface  of 
the  brain  and  forming  what  is  called  gummy  meningitis.  The 
gummata  uiay  attain  great  size.  They  start  usually  from  the  pia 
mater  and  are  due,  as  in  the  case  of  tubercle,  to  the  irritative 
action  of  some  infective  organism.  The  gumma  is  irregular  in 
shape ;  it  has  a  somewhat  thick  grayish  periphery  and  often  a 
yellowish  centre,  the  appearances  differing  w'ith  the  age  of  the 
tumor.  Microscopically  it  is  found  to  consist  of  small  round  cells 
and  spindle  cells  with  various  broken-down  nerve-tissue  elements. 
It  presents  in  the  interior  the  evidence  of  cheesy  degeneration, 
somew^hat  like  that  in  tubercle,  but  less  marked.  There  is  a  pecul- 
iar development  of  fibrous  tissue  in  the  syphilitic  growths  which 
distinguishes  them  somewhat.  Besides  this,  the  blood-vessels 
are  numerous  in  the  periphery  and' show  evidences  of  endarteritis 
and  periarteritis.  The  distinctions  between  gumma  and  tu- 
bercle are  the  less  amount  of  cheesy  degeneration  in  the  centre 
of  the  former,  its  more  irregular  appearance,  the  presence  of 
arteritis  and  vascularization,  the  absence  of  giant  cells  and  of 
tubercle  bacilli. 


TUMORS   OF   THE   BRAIN.  31)1 

Actinomycosis  is  a  form  of  infectious  tumor  which  sometimes 
extends  from  the  face  and  neck  into  the  brain,  leading  to  inflam- 
matory processes,  however,  rather  than  true  tumors.  No  other 
neoplasms  of  infections  origin  attack  the  brain  unless  glioma  be 
found  to  be  of  that  nature. 

Glioma  may  occur  in  any  part  of  the  brain,  but  is  most  fre- 
quently found  in  the  cerebrum.  It  is  the  only  tumor  which  is 
peculiar  to  the  nervous  centre,  being  developed  from  the  neu- 
roglia tissue  which  forms  the  supporting  structure  of  these  centres. 
Glioma  originates  in  the  white  matter  of  the  nerve  centre  and 
not  from  the  membranes  or  fibrous  structures.  It  may  grow  to 
a  very  large  size  and  is  the  form  of  brain  tumor  which  becomes 
the  largest.  Gliomatous  tumors  measure  from  three  to  eight  or 
more  centimetres  in  diameter.  In  appearance  the  glioma  can 
be  scarcely  distinguished  from  the  brain  substance  itself,  but 
usually  looks  like  either  pale  or  congested  gray  matter,  or  it  may 
have  a  yellowish  or  gelatinous  a^Dpearance.  The  tumor  is  very 
vascular  and  it  may  show  the  results  of  hemorrhages.  The  cen- 
tral part  sometimes  breaks  down,  forming  cavities  or  cysts.  The 
tumor  may  grow  very  rapidly,  infiltrating  the  normal  tissue.  In 
those  cases  there  is  hardly  any  definite  boundary  between  the 
tumor  and  the  normal  tissue.  In  other  cases  the  tumor  grows 
slowly,  but  rarely  if  ever  becomes  encapsuled.  Microscopically 
it  is  found  to  consist  of  small  cells  with  delicate  fibrous  prolonga- 
tions, these  being  the  glia  cells.  The  tumor  is  very  vascular 
and  its  whole  appearance  is  suggestive  of  an  inflammatory  pro- 
cess rather  than  a  new  growth ;  the  inflammatory  process  being 
one  in  which  the  neuroglia  tissue  reacts  to  the  inflammatory  irri- 
tant. Gliomata  may  undergo  certain  changes,  e.g.,  a  mucous  de- 
generation of  the  cells  takes  place,  forming  a  myxo-glioma.  When 
there  is  with  the  neuroglia-cell  i^roliferation  a  rich  proliferation 
of  round  cells  from  the  connective  tissue  it  is  called  a  glio-sar- 
coma.  When  the  tumor  is  situated  near  the  surface,  involves  the 
membranes,  and  grows  slowly,  with  an  increase  in  fibrous  tissue, 
it  is  called  a  fibro-giioma.  When  the  gliomatous  growth  is  very 
firm  and  hard,  the  fibrous  portion  of  the  glia  tissue  predominates ; 
it  constitutes  a  nodule  such  as  is  found  in  multiple  sclerosis,  and 
these  hard  gliomata  are  sometimes  called  neuro-gliomata. 

Sarcoma.  The  sarcoma  and  its  various  modifications  form 
perhaps  the  most  important  and  almost  the  most  frequent  of  the 
brain  tumors.  The  sarcoma  is  a  tumor  of  connective-tissue  origin ; 
it  develops,  therefore,  from  the  brain  membranes  or  from  the 
sheaths  of  the  blood-vessels.  Sarcomas  may  be  single  or  multi- 
ple. They  may  be  of  all  shapes  and  they  grow  to  very  varying 
sizes.  They  often  develop  a  capsule.  They  may  be  either  pri- 
mary or  secondary.     Their  growth  is  often  j-apid.     They  are 


392  DISEASES    OF   THE   NERVOUS   SYSTEM. 

white  or  grayish  in  appearance  or  may  be  somewhat  yellowish, 
dependent  on  the  iDredominance  of  the  different  kinds  of  cells 
and  blood-vessels.  Microscopically  they  are  made  up  of  small 
round  cells,  spindle  cells,  and  other  cells  of  various  sizes  and 
forms.  They  contain  often  considerable  fibrous  tissue.  They 
contain  blood-vessels,  but  are  not  richly  vascular.  The  essential 
characteristic  of  the  sarcoma  is  the  rich  development  of  round 
cells  and  spindle  cells ;  in  other  words,  its  rich  cellular  contents. 
Sarcomata  are  peculiar  in  undergoing  many  modifications  •  thus 
sometimes  fibrous  tissue  develops  largely  and  the  tumor  is  called 
a  fibro-sarcoma ;  sometimes  the  tumor  undergoes  mucous  degen-' 
eration  and  is  called  a  myxo-sarcoma.  There  may  be  a  breaking 
down  of  the  centre  with  the  formation  of  cysts.  There  may  be  a 
development  of  pigment.  Xot  infrequently  a  sarcomatous  pro- 
cess invades  a  glioma  and  we  hav^e  a  mixture  of  a  sarcoma  and 
glioma.  Sarcomatous  tumors  sometimes  have  an  alveolar  struc- 
ture. These  tumors  contain  endothelial  cells  derived  from  the 
lymphatics  and  are  called  endothelioma.  When  sarcomata  de- 
velop from  the  dura  mater  and  are  slow  in  growth  there  may  be 
calcareous  deposits  in  them  and  they  are  called  psammomata. 

The  fibroma  is  a  very  ra^'e  brain  tumor,  unless  the  pachionian 
bodies,  when  enlarged  and  hardened,  may  be  so  considered. 

Osteoma  is  not  x^articularly  rare,  developing  in  the  form  of 
bony  plates  in  the  dura,  falx,  or  tentorium.  Osteomata  in  the 
brain  substance  are  merely  pathological  curiosities. 

Enchondromata,  lipomata,  and  angiomata  are  rare  and  have 
no  practical  importance. 

Occasionally  neuromata  or  false  neuromata  are  found  devel- 
oping on  the  roots  of  the  cranial  nerves. 

Cancer  is  relatively  a  very  rare  affection  of  the  brain,  especially 
as  a  primary  development.  It  usually  arises  from  the  membranes 
of  the  brain.  Cancer  is  not  infrequently  multiiDle  and  is  usually 
of  the  soft  or  colloid  character. 

Parasitic  growths.  Parasitic  tumors  are  extremelj^  rare  in 
this  country.  The  only  forms  which  are  found  are  the  echino- 
coccus  and  the  cysticercus  cellulosse.  The  echinococcus  produces 
hydatid  cysts  which  may  be  large  or  small,  few  or  many,  and  are 
usually  all  upon  the  surface  of  the  brain.  They  are  much  rarer 
than  the  cysticerci.  These  form  cysts  which  are  usually  multi- 
ple, slow  in  growth,  lie  upon  the  surface  of  the  brain  or  in  the 
ventricles,  are  encapsuled,  and  show  no  symptoms  (Fig.  188). 

Aneurisms  are  anatomically  tumors ;  but  clinically  they  pre- 
sent some  special  symptoms  and  hence  are  described  separately. 

Diagnosis. — It  is  necessary  first  to  make  the  diagnosis  of  the 
presence  of  the  tumor,  next  of  its  location,  and  finally  of  its 
nature.     The  existence  of  a  brain  tumor  is  determined  by  the 


TUMORS   OF   THE   BRAIN. 


393 


presence  of  the  characteristic  general  symptoms— headache,  vom- 
iting, vertigo,  optic  neuritis,  mental  disturbances,  and  progres- 
sive course.  The  physician  must  bear  in  mind  the  possibilities 
of  meningitis,  abscess,  lead-poisoning,  hysteria,  and  paretic  de- 
mentia. Ver}''  often  a  localized  basilar  meningitis  of  syphilitic  or 
tubercular  origin  simulates  closely  the  presence  of  a  tumor.  Be- 
sides the  general  points  referred  to,  in  estimating  the  probabili- 
ties of  the  existence  of  a  tumor  we  must  bear  in  mind  the  age  of 
the  fjatient  and  the  existence  of  a  tuberculous  or  syphilitic  his- 
tory, the  history  of  an  injury,  of  local  tenderness,  and  of  rise  of 
cranial  surface  temperature,  and  the  presence  of  some  new  growth 


Fig.  188.— Echinococcus  Cyst  of  the  Third  Ventricle. 


in  other  parts  of  the  body,  particularly  about  the  neck  or  thorax 
or  in  the  lungs. 

The  diagnosis  of  the  location  of  the  tumor  is  based  upon  the 
rules  already  given  in  regard  to  local  diagnosis.  The  diagnosis 
of  the  nature  of  the  tumor  can  often  be  made  and  should  be  at- 
tempted. In  children,  for  example,  the  chances  of  the  tumor 
being  tubercular  are  very  great,  particularly  if  there  is  a  scrofu- 
lous diathesis  or  tubercular  disease  elsewhere.  Syphilitic  tumors 
of  the  brain  are  almost  always  accompanied  Avith  or  preceded  by 
manifestations  of  external  syphilis.  Gliomatous  tumors  occur  in 
childhood  and  early  life.  They  produce,  as  a  rule,  fewer  irrita- 
tive phenomena  and  are  accompanied  by  remissions  and  by  apo- 


39J:  DISEASES   OF   THE   NERVOUS   SYSTEM. 

plectic  or  pseudo-apoplectic  attacks  due  to  the  vascular  nature  of 
the  tumor.  Carcinomata  occur  late  in  life  and  are  usually  sec- 
ondary. 

Prognosis. — In  extremely  rare  cases  tumor  of  the  brain  ap- 
pears to  stop  growing  and  become  encapsulated  and  atrophied. 
Such  tumors  are  of  a  tubercular  or  syphilitic,  perhaps  sometimes 
of  a  sarcomatous  character.  As  a  rule,  the  brain  tumor  grows 
steadily  and  the  symptoms  of  the  disease  become  more  pro- 
nounced until  death  occurs.  The  prognosis  is  best  for  tubercle 
in  children  and  gumma  in  adults.  It  is  worse  in  those  cases  of 
glioma  and  sarcoma  which  have  a  rapid  course.  In  fact,  the 
sooner  serious  symptoms  develop,  the  more  rapid  the  general 
development  of  the  disorder,  the  sooner  does  a  fatal  termination 
come.  The  disease  lasts  on  an  average  two  or  three  years,  rang- 
ing from  a  month  to  eighteen  years. 

Treatment. — Something  can  be  done  in  cases  of  tuberculous 
tumors,  syphilitic  tumors,  and  iDossibly  in  the  sarcomatous  vari- 
ety. In  tuberculous  tumors  a  general  constitutional  and  strength- 
ening treatment  must  be  resorted  to ;  fresh  air,  tonics,  and  a  large 
amount  of  food  being  the  main  reliance.  The  utility  of  any  form 
of  tuberculin  is  as  yet  doubtful.  In  syphilitic  tumors  much  can 
be  done  by  the  usual  vigorous  antisyiDhilitic  treatment.  In  sar- 
comatous tumors,  if  they  are  suspected,  some  help  may  be  ob- 
tained from  the  internal  use  of  arsenic.  Symptomatically  we 
must  give  such  drugs  as  antipyrin,  phenacetin,  antifebrin,  code- 
ine, and  perhaps  morphine  for  the  relief  of  i^ain.  The  ice -cap 
and  leeching  often  help  the  headache  also.  Should  convulsions 
develop  the  bromides  should  be  used,  just  as  in  idiopathic  epi- 
lepsy. 

In  cases  in  which  the  location  of  the  tumor  can  be  made  out, 
the  question  of  surgical  interference  should  be  considered.  The 
percentage  of  cases  in  which  surgery  can  help  is  extremely  small. 
It  will  only  include  those  cases  in  which  the  tumor  can  be  located ; 
of  those  w^hich  can  be  located,  only  those  which  are  in  an  acces- 
sible region,  and  finally,  of  those  which  are  in  an  accessible  region, 
it  includes  those  which  are  either  superficial,  or,  if  lying  in  the 
brain  substance,  are  more  or  less  encapsulated.  The  removable 
tumors  of  the  brain  amount  to  less  than  five  per  cent.  They  are, 
in  particular,  the  sarcomatous,  syphilitic,  and  tubercular  tumors 
lying  in  the  central  or  occipital  areas.  In  many  cases  where  there 
is  some  doubt  as  to  the  localization  an  exploratory  trephining  is 
justifiable,  and  in  a  few  cases  in  which  it  is  known  that  the  tumor 
cannot  be  removed  the  trephining  for  the  simple  purpose  of  re- 
lieving pressure  is  justifiable.  It  is  probable  that  in  adults  some 
tumors  from  the  anterior  and  middle  fossa  of  the  brain  can  be 
removed.     In  children  tumors  ca-nnot  be  removed  successfully 


TUMORS   OF   THE   BRAIN.  395 

from  the  cerebellum ;  in  adults  it  is  perhaps  possible.  Operations 
for  tumors  should  be  undertaken  as  early  as  possible;  this  is  a 
fact  on  which  too  much  stress  cannot  be  laid. 


IXTRACRAXIAL  ANEURISMS. 

Intracranial  aneurisms  are  of  two  kinds—"  miliary  "  and  those 
of  large  size.  The  miliary  aneurisms  are  minute  dilatations  of 
the  vessels  and  are  always  multiple;  they  have  been  described 
under  the  head  of  cerebral  hemorrhage.  Large  aneurisms  affect 
only  the  large  cerebral  arteries  at  the  base  of  the  brain.  The 
arteries  are  affected  in  the  following  order:  middle  cerebral,  basi- 
lar, internal  carotid,  and  anterior  cerebral.  The  anterior  and 
posterior  communicating^  and  vertebral  arteries  are  occasionally 
involved,  the  posterior  cerebral  and  inferior  cerebellar  very  rarely 
(Gowers). 

M iolog I/.— ^Lales  are  affected  slightly  oftener  than  females. 
Aneurisms  occur  at  all  ages  from  ten  to  sixty;  before  ten  and 
after  sixty  they  are  extremely  rare.  Heredity  occasionally  plays 
a  part  in  predisposing  to  cerebral  aneurisms.  The  exciting  causes 
are  embolism,  esj^ecially  when  the  emboli  contain  microbes; 
syphilitic  disease,  injuries,  and  in  rare  cases  senile  degeneration. 

The  symjDtoms  are  very  indefinite;  they  resemble  to  a  consid- 
erable extent  those  of  tumor  at  the  base  of  the  brain ;  headache 
and  vertigo,  mental  dulness  and  irritation,  cranial-nerve  palsies, 
and  occasionally  hemiplegia  and  convulsions  are  noted.  Optic 
neuritis  is  rather  rare.  In  a  few  cases  the  patient  is  conscious  of 
a  murmur  or  recognizes  the  pulsating  sensation  in  the  head. 
Sometimes  Avhen  the  aneurism  is  in  the  vertebral  artery  a  mur- 
mur can  be  heard  between  the  mastoid  process  and  the  spinal 
column  (Moser). 

The  diagytosis  is  often  difficult;  it  is  based  on  symptoms  of 
tumor  at  the  base  of  the  brain  pressing  on  cranial  nerves  and  on 
motor  or  sensory  tracts.  The  effect  of  carotid  compression  should 
be  tried. 

The  2^rog)iosis  is  not  good.  In  perhaps  the  majority  of  cases 
a  rupture  of  the  vessel  occurs  in  a  few  years ;  however,  rupture  is 
not  the  inevitable  event,  and  sometimes  the  disease  becomes  sta- 
tionary or  undergoes  spontaneous  cure. 

The  treatment  of  the  disease,  if  it  can  be  recognized,  is  the 
same  as  that  for  aneurism  elsewhere  so  far  as  drugs  are  con- 
cerned ;  surgically  the  common  carotid  may  be  tied  and  perhaps 
the  vertebral  if  the  aneurism  is  believed  to  be  connected  with 
that  artery  or  with  the  basilar. 


396  DISEASES  OF  THE  NERVOUS  SYSTEM. 


Syphilis  of  the  Nervous  System. 

Syphilis  is  an  extremely  important  factor  in  the  causation  of 
the  organic  diseases  of  the  nervous  system.  Nervous  syphilis 
makes  up  over  ten  per  cent  of  all  the  hereditary  forms,  and  while 
in  adult  life  the  specific  virus  attacks  nerve  centres  relatively  less 
often,  yet  it  is  a  factor  whose  importance  is  very  great.  In  the 
previous  descriptions  of  nervous  diseases  we  have  referred  to  the 
syphilitic  element  in  connection  with  etiology  and  pathology; 
but  syphilis  produces  upon  the  nervous  system  certain  forms  of 
disease  which  are  characteristic,  hence  it  is  best  to  take  a  brief 
survey  of  the  effects  of  this  infection  independently.  Syphilis  is 
beyond  much  question  the  result  of  an  infection  by  a  microbe, 
and  the  result  of  the  activity  of  this  microbe  upon  the  nervous 
centres  is  to  produce  a  condition  which  is  really  a  form  of  inflam- 
mation. The  reader  can  best  understand  syphilitic  disorders, 
therefore,  by  remembering  that  they  are  all  forms  of  an  inflam- 
mation. The  syphilitic  infiltration  is  simply  an  exudative  in- 
flammation with  a  specific  exudate;  the  syphilitic  gumma  is  a 
deposit  of  this  exudation  analogous  somewhat  to  an  abscess. 
Syphilis  attacks  chiefly  the  membranes  of  the  brain  and  spinal 
cord  and  the  blood-vessels  of  these  organs;  in  particular  the  base 
of  the  brain  and  the  blood-vessels  that  supply  this  region  are 
affected.  Syphilis  acts  on  the  nervous  centres  in  four  ways  •.  it 
produces  meningeal  exudation  and  inflammation,  it  forms  gum- 
matous tumors,  it  causes  arteritis,  and  it  leads  to  degenerations. 

Etiology. — A  neuropathic  constitution  probably  predisposes 
to  the  development  of  nervous  syphilis.  The  age  at  which  it  occurs 
most  frequently  is  between  twenty  and  forty,  but  it  may  occur  at 
all  periods  of  life  from  infancy  up.  It  attacks  men  oftener  than 
women  in  the  i^roportion  of  about  seven  to  one.  Hereditary 
syphilis  makes  up  about  three  per  cent  of  the  cases.  Inadequate 
and  improper  treatment  of  ttie  disease  at  first  favors  the  develop- 
ment of  nervous  syphilis  later.  The  neglect  in  particular  of  the 
early  use  of  iodide  of  potassium  tends  to  render  a  i^erson  more 
liable  to  have  the  nervous  centres  attacked.  The  use  of  alcohol, 
excesses  in  the  way  of  severe  bodily  exercise,  severe  mental  strain, 
and  overwork  predispose  to  the  development  of  the  disease;  in- 
juries undoubtedly  haA^e  a  similar  effect.  The  time  after  the 
infection  when  the  disease  is  most  apt  to  occur  is  the  third  year, 
but  it  is  not  infrequent  between  the  second  and  the  tenth  years, 
and  it  is  possible  for  nerve  syphilis  to  develop  from  within  a  few 
months  up  to  thirty  years  after  the  infection. 

Symptoms. — Since  syphilitic  changes  may  attack  any  part  of 
the  nervous  centres,  the  symptomatology  of  nerve  syphilis  is 


TUMORS   OF   THE   BRAIN.  397 

necessarily  a  varied  one.  The  reader  can  perhaps  best  under- 
stand the  way  in  which  the  disease  acts  by  having  presented  first 
a  series  of  tables  showing  on  the  one  side  the  clinical  symptoms, 
on  the  other  the  chief  anatomical  changes  that  underlie  them. 
The  first  table  presents  the  symptoms  of  syphilis  of  the  brain, 
which  is  unquestionably  the  most  connnon  form.  The  next  table 
shows  the  symptoms  of  syphilis  of  the  cerebro-spinal  system,  a 
form  which  ranks  second  in  frequency.  Third  we  have  syphilis 
of  the  spinal  cord  alone,  which  is  somewhat  rarer,  and  last  and 
rarest  of  all  we  have  syphilis  of  the  nerves.  In  addition  to  these 
four  forms  of  syphilitic  manifestation  we  have  two  diseases 
which  are  acknowledged  to  be  sequelae  of  syphilis  and  which  are 
called  post-syphilitic  degenerative  processes. 

I.  Syphilis  of  the  Brain. 

Clinical  Symptoms.  Anatomical  Change. 

Severe  headache,  vomiting,  vertigo,  men-  Gummatous  inflammation  of  the  base  in- 

tal  dulness,  and  irritability,  attacks  of  volving  nerve  roots,  or  gummatous  in- 

somnolence  or  coma,  convulsions,  era-  flammation  of  convexity,  arteritis,  and 

nial-nerve  palsies,  optic  neuritis,  hem-  phlebitis, 
iplegia,  polyuria,  and  polydipsia. 

II.  Cerebro-spinal  Syphilis. 
Many  of  the  brain  symptoms  as  above,        Gummatous  basilar  meningitis  ;  diffuse, 
spastic  paraplegia  with  spinal  pains  disseminated,   or   localized   meningo- 

and  involvement  of  sphincters.  myelitis. 

III.  Spinal  Syphilis. 

Paraplegia  with  pains,  Brown-Sequard       Meuingo-myelitis,     gumma,    localized 

paralysis.  softenings  from  obliterative  arteritis. 

IV.  Syphilis  op  Nerves. 
Cranial-nerve     palsies,     cauda    equina       Root  neuritis,  gummatous  neuritis, 
sj'mptoms,  local  palsies  of  peripheral 
nerves.  ♦- 

v.— Post-syphilitic  Degenerative  Processes. 
Locomotor  ataxia ;  general  paresis. 

Taking  up  these  different  forms  of  nerve  syphilis  in  order,  I 
will  give  some  further  details  with  regard  to  each  of  them. 

I.  Syphilis  of  the  brain  in  its  most  common  form  shows  itself 
by  a  gradual  development  of  severe  and  persistent  headache.  This 
is  usually  associated  with  vertigo,  sometimes  with  nausea  and 
vomiting.  After  the  headache  has  developed  and  has  lasted  for 
a  time,  or  even  without  much  delay,  there  comes  on  sometimes 
an  attack  of  hemiplegia.  Preceding  the  hemiplegia,  or  in  some 
cases  without  the  hemiplegia,  there  are  paralyses  of  the  cranial 
nerves,  more  especially  of  the  nerves  of  the  eye.  Optic  neuritis 
is  somewhat  frequent.  There  may  be,  before  any  paralyses  de- 
velop, attacks  of  epileptic  convulsions,  either  general  or  partial. 


398  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Without  any  paralyses  or  with  simply  cranial-nerve  paralyses 
there  may  develop  attacks  of  somnolence  and  coma.  Even  if 
such  attacks  do  not  appear  the  patient  often  shows  a  mental  irri- 
tability and  weakness,  a  slowness  of  the  reasoning  process,  and 
incapacity  to  fix  the  attention  such  as  is  observed  in  connection 
with  brain  tumors,  only  with  nerve  syphilis  these  symptoms  are 
not  usually  so  marked.  Polyuria  and  polydijDsia  are  symptoms 
which  are  occasionally  met  with.  It  will  be  seen  that  the  syph- 
ilitic poison  produces  very  various  manifestations  when  it  attacks 
the  brain.  The  characteristic  features  are  this  variability  in  the 
symptoms  and  their  remittent  character.  Elaborate  systems  of 
clinical  classification  might  be  made  out  of  these  v^arious  groups, 
but  it  will  be  sufficient  for  the  present  purpose  to  call  attention 
to  the  fact  that  the  intense  headaches,  optic  neuritis,  cranial- 
nerve  palsies,  attacks  of  somnolence  and  coma,  and  hemiplegia 
associated  with  some  of  the  foregoing  symptoms  are  characteris- 
tic of  most  of  the  forms.  The  reason  for  the  peculiar  symptoms 
in  brain  syphilis  is  manifest  when  it  is  known  that  the  lesion 
most  commonly  found  underlying  them  is  a  gummatous  menin- 
gitis Avhich  has  a  special  predilection  for  the  base  of  the  brain. 
In  particular  it  seems  to  attack  the  interpeduncular  space  and 
the  neighborhood  of  the  optic  chiasm  and  the  surface  of  the  pons 
Varolii.  This  gummatous  meningitis  consists  of  a  syphilitic  in- 
flammatory exudate  which  surrounds,  presses  upon,  and  injures 
cranial  nerves,  attacks  the  arteries  of  the  base,  producing  an 
obliterating  arteritis  and  conseqaent  softenings,  with  the  hemi- 
plegia which  is  so  often  a  manifestation  of  the  disease.  Much 
less  frequently  the  inflammatory  j^rocess  attacks  the  coiivexity, 
and  then  it  assumes  the  form  of  a  gummatous  patch  which 
produces  cortical  irritation  wath  headaches,  mental  disturbances, 
and  convulsions. 

II.  The  next  form  of  nervous  syphilis  is  the  cerebrospinal. 
In  this  we  have  almost  exactly  the  same  conditions  and  symp- 
toms so  far  as  the  brain  is  concerned;  but  in  addition  there  are 
symptoms  due  to  more  or  less  diffuse  syphilitic  inflammation  of 
the  pia  mater  of  the  spinal  cord.  The  syphilitic  process  often 
extends  into  the  spinal  cord,  producing  an  obliteration  of  the 
arteries  and  softening  with  the  symptoms  of  a  transverse  or  a 
central  myelitis.  Thus  we  have  combined  the  symptoms  of  cere- 
bral syphilis  and  paraplegia  with,  as  a  rule,  considerable  pain 
in  the  back,  produced  by  the  involvement  of  the  meninges. 

III.  The  third  type  of  syphilis  is  the  spinal  form.  The  symp- 
toms in  spinal  syphilis  are  usually  those  of  a  transverse  myelitis, 
involving,  in  the  writer's  experience,  most  often  the  lower  paj*t  of 
the  dorsal  and  upper  part  of  the  lumbar  cord.  This  myelitis 
usually  comes  on  rather  slowly  with  the  ordinary  symptoms  of  a 


TUMORS   OF  THE   BRAIN.  399 

chronic  or  subacute  transvei-se  myelitis.  It  is  probable  that 
syphilis  is  a  much  uiore  frequent  factor  in  the  production  of  so- 
called  transverse  myelitis  than  is  usually  supposed.  The  ana- 
tomical process  underlying  it  is  that  of  a  meningitis  which  passes 
along  the  septa  into  the  substance  of  the  cord,  involves  the 
arteries  of  the  cord,  and  produces  a  more  or  less  complete  soften- 
ing of  the  part.  The  only  truly  inflammatory  process,  therefore, 
is  that  which  is  produced  in  the  meninges,  connective  tissues, 
and  arteries.  The  anatomical  changes  in  the  cord  substance  are 
mainly  those  of  softening  with  reactive  inflammation.  Spinal 
syphilis  may  show  itself  also  by  the  development  of  gummatous 
nodules  which  grow  from  the  meninges,  press  upon  the  cord,  and 
IDroduce  the  symptoms  of  a  spinal  tumor.  Spinal  syphilis  may 
also  develop  itself  in  three  or  four  different  foci,  producing  the 
symptomatology  of  disseminated  myelitis. 

IV.  Syphilis  of  the  nerves.  Syphilis  rarely  affects  the  periph- 
eral nerves;  there  are,  however,  occasional  deposits  of  syphilitic 
exudate  producing  the  ordinary  symptoms  of  irritation  and  com- 
pression of  nerves.  There  is  said  to  be  a  form  of  multiple  neuri- 
tis produced  by  syphilis,  but  its  actual  existence  has  not  yet  been 
absolutely  demonstrated.  Syphilis  has  been  known  to  attack 
the  roots  of  the  cranial  nervcjs,  producing  a  root  neuritis;  and  it 
is  very  apt  to  attack  the  roots  of  the  spinal  nerves  when  the 
spinal  membranes  are  involved. 

V.  The  post-syphilitic  degenerative  processes  are  locomotor 
ataxia  and  general  paresis.  Occasionally  it  happens  that  the 
syphilitic  deposits  in  the  spinal  cord  may  produce  lesions  some- 
what like  those  of  locomotor  ataxia,  and  in  this  case  there  will 
be  a  train  of  symptoms  which  also  resemble  this  disease.  In  true 
locomotor  ataxia,  however,  the  process  is  never  in  any  sense  a 
syphilitic  one.  The  syphilitic  poison  seems  to  so  affect  the  ner- 
vous centres  as  to  predispose  them  to  the  peculiar  degeneration 
characteristic  of  tabes.  Syphilis  may  also  produce  a  chronic 
meningo-encephalitis  which  will  manifest  itself  by  symptoms  re- 
sembling to  a  considerable  extent  general  paralysis;  but  it  is  very 
generally  conceded  that  true  general  paresis  is  not  a  syphilitic 
disorder.  Syphilis,  however,  seems  to  predispose  to  it,  just  as  it 
does  to  locomotor  ataxia. 

Hereditary  ^ijphilis.— Inherited  syphilis  will  lead  to  anatomi- 
cal changes  and  clinical  manifestations  resembling  in  all  respects 
those  of  acquired  syphilis.  Inherited  syphilis,  in  other  words, 
may  produce  headaches,  cranial-nerve  palsies,  hemiplegia,  epi- 
lepsy, mental  disorders,  and  paraplegia.  The  disease  probably 
is  the  cause  of  a  considerable  proportion  of  the  cases  of  chronic 
hydrocephalus  and  of  many  of  the  cases  of  so-called  tubercular 
meningitis.     The  peculiarities  of  hereditary  syphilis  show  them- 


400  DISEASES   OF   THE   NERVOUS   SYSTEM. 

selves  rather  more  in  diffuse  symptoms  such  as  would  be  attrib- 
uted to  a  meningitis  of  the  convexity ;  in  other  words,  convul- 
sions and  mental  weakness  are  rather  more  frequent,  while 
hemiplegia  and  cranial-nerve  palsies  are  comparatively  rare. 
Hereditary  syphilis  also  very  rarely  indeed  attacks  the  spinal  cord, 
although  it  is  not  unlikely  that  it  is  a  factor  in  the  production  of 
some  of  the  hereditary  scleroses  of  that  organ.  Hereditary  syph- 
ilis develops  at  any  time  from  birth  to  the  eighteenth  year,  but 
most  commonly  under  the  age  of  five  years. 

Pathology.— I  have  already  given  some  indications  of  the  path- 
ological changes  produced  by  syphilis.  The  disease  affects  the 
nervous  system  (1)  by  producing  a  meningitis  with  infiltration, 
(2)  by  producing  gummatous  masses,  (3)  by  producing  an  inflam- 
mation of  the  arteries,  and  (4)  by  so  influencing  the  nervous  sys- 
tem as  to  lead  to  the  development  of  degenerative  diseases.  Of 
all  these  forms  of  anatomical  change  it  is  the  arteries  that  are 
most  often  affected,  and  particularly  the  arteries  at  the  base  of 
the  brain. 

Syphilitic  meningitis  is  characterized  by  the  proliferation  of 
round  cells  and  the  preponderance  of  an  exudate  which  has  a 
tendency  to  infiltrate  into  the  nervous  tissues.  The  anatomical 
characteristics  of  the  syphilitic  gumma  must  be  studied  in  special 
text-books.  The  inflammation  of  the  arteries  attacks  first  the 
external  coat  and  adventitia,  producmg  there  an  enormous  mul- 
tiplication of  round  cells.  The  external  coat  becomes  weakened, 
and  as  a  result  there  develops  beneath  it,  between  the  intima 
and  the  elastic  layer,  another  exudate  which  constitutes  what  is 
known  as  endarteritis.  In  syphilitic  arteritis,  therefore,  there  is 
both  a  periarteritis  and  an  endarteritis;  the  former  being  usu- 
ally the  primary  and  most  essential  process.  The  endarteritis, 
however,  as  it  develops  gradually  produces  an  occlusion  of  the 
arteries.  This  cuts  off  the  circulation  of  the  blood  and  leads  to 
softening  of  the  part.  There  is  also  a  development  of  a  hyaline 
degeneration  in  the  arteries  which  some  regard  as  a  very  essential 
part  of  the  anatomical  change. 

Diagnosis.— The  diagnosis  of  nervous  syphilis  is  based  upon 
the  history  of  an  infection,  the  irregularity  and  fugacity  of  the 
symptoms,  the  intense  headaches,  the  presence  of  an  optic  neu- 
ritis, the  age  of  the  patient,  and  the  results  of  treatment.  In 
estimating  the  importance  of  the  history  of  infection,  it  should  be 
remembered  that  the  third  year  after  infection  is  the  serious  one 
for  the  development  in  particular  of  those  symptoms  produced 
by  obliterating  arteritis.  In  hereditary  syphilis  the  presence  of 
the  Hutchinson  teeth,  the  hazy  cornea,  and  deafness  or  other  ear 
trouble  help  us  in  diagnosis.  The  headache  of  syphilis  is  rather 
characteristic.     It  may  attack  any  part  of  the  head,  but  is  usu- 


TUMORS   OF   THE   BRAIX.  401 

ally  unilateral  or  irregular,  or  again  it  may  be  bilateral  in  its  dis- 
tribution. The  pain  is  very  intense  and  sometimes  exhibits  a 
certain  periodicity.  It  is  usually  worse  at  night.  It  is  apt  to 
last  continuously  for  from  five  days  to  three  or  four  ^veeks. 
Headache  of  this  character,  foJlowed  by  the  paralysis  of  one  or 
more  cranial  nerves  or  by  an  attack  of  hemiplegia,  is  extremely 
suggestive  of  syphilis.  Optic  neuritis  is  very  liable  to  occur 
when  the  disease  shows  other  evidences  of  being  situated  at  the 
base  of  the  brain.  This  optic  neuritis  is  associated  with  contrac- 
tion of  the  visual  field,  and  a  characteristic  feature  of  this  con- 
traction is  that  it  varies  a  great  deal  from  week  to  week.  The 
sex  and  age  of  the  patient  may  be  taken  into  consideration  in 
weighing  the  evidence,  and  finally  the  prompt  effects  of  the  use 
of  iodide  of  potassium  should  have  very  decided  weight. 

Prognosis.— It  is  very  difficult  to  give  definite  facts  regarding 
the  prognosis  of  syphilis.  Unquestionably  the  outlook  is  much 
more  favorable  than  it  is  for  any  other  organic  disease  of  the 
nervous  system.  When  the  syphilitic  process  has  not  produced 
so  much  arterial  disease  as  to  lead  to  obliteration  of  vessels  and 
softening,  a  very  great  degree  of  improvement  and  even  a  recov 
ery  may  be  expected.  So  far  as  injuries  to  the  nerves  or  nerve 
roots  go,  we  can  generally  expect  a  great  improvement  or  cure. 
Lesions  of  the  convexity  are  usuallj^  amenable  to  treatment. 
Syphilitic  hemiplegia  has  a  not  much  better  prognosis  than 
hemiplegia  from  other  causes.  Syphilitic  myelitis  has  a  not  very 
good  prognosis,  but  it  is  better  than  that  of  myelitis  due  to 
trauma.  Nervous  syphilis  may  last  from  one  to  three  or  four 
years.  The  effects  of  the  disease  may,  if  nerve  tissue  is  destroyed, 
last  a  lifetime. 

Treatment.— \b  regards  the  prophylaxis,  it  is  important  that 
persons  who  have  become  infected  by  syphilis  should  be  treated 
w  ith  iodide  of  potassium  in  the  second  as  well  as  the  third  stage 
of  the  disease.  After  the  first  year  at  least,  the  patient  should 
not  neglect  to  take  a  certain  amount  of  iodide  of  potassium  four 
times  a  year,  each  course  of  treatment  lasting  six  weeks.  The 
patient  should  be  warned  against  indulging  in  alcohol,  against 
all  excesses,  mental  as  Avell  as  physical.  A  laborious  life  full  of 
worry  and  anxiety,  in  which  the  patient  attempts  to  help  him- 
self along  with  stimulants,  is  surely  provocative  of  the  develop- 
ment of  nervous  syphilis. 

The  treatment  of  the  disease  when  it  has  appeared  consists, 
mainly  in  the  administration  of  iodide  of  potassium  or  sodium. 
This  should  be  given  in  beginning  doses  of  ten  grains  three  times 
a  day  and  increased  gradually  until  the  maximum  amount  which 
the  patient  can  bear  is  taken.  This  maximum  is  usually  between 
three  and  four  hundred  grains  a  day.  In  some  cases  it  is  un- 
26 


402  DISEASES   OF   THE   NERVOUS   SYSTEM. 

portant  to  give  luore  than  this — as  much,  that  is  to  say,  as  two 
liundred  grains  three  times  a  day,  and  it  is  the  general  experience 
olf  American  neurologists  that  results  can  be  obtained  by  these 
large  doses  which  cannot  be  obtained  by  smaller  ones.  In  my 
own  experience  I  have  known  a  i^atient  to  take  five  hundred 
grains  three  times  a  day  for  a  considerable  time  without  harm, 
and  indeed  with  benefit.  Usually,  however,  such  extraordinary 
doses  are  rarely  needed.  It  is  found  that,  as  a  rule,  patients  tol- 
erate large  doses  of  iodide  quite  as  well  as  smaller  ones,  and  some- 
times the  iodism  produced  by  small  doses  disappears  when  large 
doses  are  given.  The  drug  is  best  administered  largely  diluted 
with  water  or  with  Vichy  or  in  milk,  and  taken  after  meals. 
Some  persons  bear  it  better  before  meals.  It  is  occasionally  ad- 
visable to  combine  mercury  with  the  iodide.  This  may  be  given 
in  the  form  of  the  bichloride  or  by  an  inunction.  Other  drugs 
which  are  of  value  are  the  ordinary  tonics  such  as  iron,  quinine, 
and  the  bitters  and  mineral  acids.  Plenty  of  good  food,  out -door 
air,  and  all  those  things  which  will  improve  the  general  health 
of  the  patient  are  indicated. 


CHAPTEK    XXL 

FUNCTIONAL   NERVOUS  DISEASES. 

Functional  nervous  diseases  are  those  in  which  no  definite 
known  anatomical  change  underhes  the  morbid  phenomena. 
On  this  account  it  is  customary  to  classify  them  on  a  clinical 
basis.  We  can,  however,  also  make  etiological  and  pathogenic 
subdivisions.  Applying  such  a  method  now,  we  have  two  broadly 
distinguished  classes:  the  primary,  or  degenerative,  and  the 
secondary,  or  acquired  neuroses.  Such  a  classification  is  suggest- 
ive and  helpful,  though  not  perfectly  correct,  because  several 
factors  often  enter  into  the  cause  of  the  same  neurosis. 

Primary  neurasthenia,  hypochondriasis. 

Epilepsy. 

Hysteria  major. 

Hereditary  chorea. 

General  spasmodic  tics. 

Myotonia. 


Primary 
degenerative  ^ 
neuroses. 


'  r  o  m  infectious, 
autocthonous, 
and  mineral  poi- 
sons. 


Acquired 
neuroses. 


Chorea. 
I    Tetanus. 
J    Tetany. 
I   Rabies. 

Tremor. 
(^  Neuralgia. 

Neurasthenia. 


Exhaustion      and 
shock  neuroses. 


Acquired    degener- 


I  Hysteria. 
]  Exoi>hthalmic  goitre. 
[  Occupation  neuroses. 
r  Tic  douloureux. 


\   Local  si^asmodic  ties, 
ative  neuroses.         i  j^^^^^^^^^  ^gitans. 


Miscellaneous. 


(   Vasomotor,     trophic,      and 
(       sleep  disorders. 


THE   DEGENERATIVE    NEUROSES. 
Epilepsy. 
Idiopathic  epilepsy  is  a  chronic  functional  disorder  character- 
ized by  periodical  seizures  attended  with  loss  of  consciousness  and 
usually  with  convulsions.     Mental  disturbances  may  accompany 
or  take  the  place  of  the  convulsions. 


404  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Symptomatic  epilepsy  is  a  form  in  which  the  periodic  convul- 
sive attacks  are  due  to  gross  organic  changes  in  the  brain. 

Jacksonian  or  partial  epilepsy  is  a  form  of  symptomatic  epi- 
lepsy usually,  and  is  characterized  by  periodic  convulsions  affect- 
ing only  certain  groups  of  muscles,  and  often  unattended  by  loss 
of  consciousness, 

Hystero-epilepsy  is  not  ejDilepsy,  but  a  form  of  hysteria. 

Eclampsia  or  acute  epilepsy  is  the  name  given  to  a  single 
isolated  attack  of  convulsions.  It  is  generally  of  the  symptomatic 
type. 

Reflex  epileptiform  convulsions  are  considered  to  form  a  dis- 
tinct tyi3e  by  some  (Starr).  In  this  class  of  cases  peripheral  nerve 
irritations  produce  severe  or  mild  epileptic  attacks  which  are 
often  very  frequent  in  occurrence. 

Idioi)athic  epilepsy  shows  itself  in  three  rather  distinct  types 
of  attacks,  viz. :  that  of  severe  attacks,  called  the  grand  mal  ; 
that  of  minor  attacks,  the  petit  mal;  and  the  rarer  larvated 
forms  characterized  by  acute  mental  disorder  and  called  psyr^iical 
epilepsy  or  the  psychical  epileptic  equivalent. 

Etiology. — Predisposing  causes :  Heredity  is  the  most  potent  of 
any  single  influence.  A  history  of  epilepsy  or  insanity  is  found 
in  the  famih'-  in  about  one-third  of  the  cases  and  rather  more  on 
the  paternal  side.  Alcoholism  and  the  intermarriage  of  neurotic 
persons  contribute  powerfully  to  i^roduce  the  convulsive  ten- 
dency in  children.  Powerful  emotions  during  pregnancy,  ac- 
couchement injuries,  and  syphilis  have  some  influence.  More 
cases  occur  in  the  country  than  the  city,  more  in  temj^erate 
climates,  and  more  among  in-bred  races.  All  American  statistics 
(Putzel,  Hamilton,  Hammond,  Starr,  and  myself — 186  cases)  show 
a  slight  preponderance  among  males.  European  observers  find 
it  the  other  way. 

Age.—T\ie  epileptic  age  is  between  ten  and  twenty,  and  still 
more  definitely  between  ten  to  fifteen.  In  three-quarters  of  the 
cases  the  disease  begins  before  the  age  of  twenty;  in  one-sixth  of 
nxy  cases  before  the  age  of  five.  After  twenty  the  danger  of  epi- 
lepsy is  slight,  andtwhen  it  occurs  it  is  usually  due  to  accidental 
causes,  like  syphilis,  alcoholism,  or  plumbism.  Idiopathic  epi- 
lepsy, however,  may  develop  even  after  sixty.  The  accompany- 
ing table  shows  graphically  the  relation  of  age  to  the  develop- 
ment of  epilepsy,  chorea,  and  neuralgias. 

Exciting  causes.  Exciting  causes  are  not  present  in  the  ma- 
jority of  cases.  The  most  important  are  the  occurrence  of  rickets 
at  the  time  of  dentition,  fright,  injury  to  the  head,  sunstroke,  in- 
fectious diseases,  especially  scarlatina,  masturbation,  alcoholism, 
and  syphilis.  Masturbation  is  a  real  but  rare  cause,  so  also  is 
syphilis.     The  so-called  reflex  causes  are  ocular  and  auditory  irri- 


EPILEPSY. 


405 


tations,  worms,  dyspeptic  states,  dental  irritations,  lesions  in- 
volving peripheral  nerves.  Some  American  observers  put  nmch 
stress  on  the  importance  of  ocular  irritations;  European  writers 
have  laid  more  emphasis  on  disease  of  the  ear.  Probably  the 
gastro-intestinal  tract  and  genital  organs  furnish  the  most  im- 
portant exciting  irritations.      True  idiopathic  epilepsy  may  be 


Percentage 

of 
total  cases 

up  to 
end  of 
5Vr 

to 
7th 

to 
15'^ 

20^ 

to 

31'^ 

to 

40^ 

4P.^ 

to. 

50^.' 

51'.' 
to 

61  ^^ 
to 

60% 

50% 

40  X 

30% 

r'' 

,--^^ 

\ 
A^ 

20% 

; 

/\ 

/- 

"A, 

J  / 

V 

\ 

lOX 

f^ 

r^ 

r^ 

\ 

// 

// 

/ 

V- 

V 

^ 

\ 

Fig.  loJ.— Table  showing  Percentage  of  Cases  of  Epilepsy,  Chorea,  and 
Neuralgia  Occurring  at  Each  Half  Decade  and  (after  20)  Each  Decade. 
Double  line,  epilepsy;  dotted  line,  chorea;  single  line,  neuralgia. 

brought  out  by  peripheral  irritations ;  more  rarely  there  occurs 
only  a  reflex  epileptiform  neurosis. 

SymiAoms  of  the  Convulsion.— The  patient  often  feels  some 
premonitory  symjDtoms  for  a  few  hours  or  a  day,  consisting  of 
general  malaise,  irritability,  or  giddiness.  The  attack  begins  in 
about  half  the  cases  with  a  peculiar  sensation  called  the  aura. 
Often  also  a  loud  cry  is  uttered  and  the  patient  falls  unconscious 
to  the  ground.  The  face  is  pale,  the  eyes  are  open  and  turned  up 
and  to  one  side  and  the  pupils  dilated.  The  head  is  drawn  back 
or  to  one  side,  and  the  whole  body  is  in  a  state  of  rigidity  or  tonic 
spasm.  The  arms  are  slightly  drawn  out  from  the  trunk,  the 
forearms  and  wrists  flexed,  the  fingers  clinched  or  flexed  in 
other  ways,  the  legs  and  feet  extended.     This  tonic  stage  lasts 


406  DISEASES   OF  THE   NERVOUS   SYSTEM. 

for  fifteen  or  twenty  seconds ;  the  face  becomes  congested  and  then 
hvid  from  compression  of  the  veins  of  the  neck  and  stoppage  of 
respiration.  Gradually  jerky  movements  of  the  face  and  limbs 
begin  and  the  stage  of  clonic  spasm  sets  in.  The  trunk  and  limbs 
are  now  alternately  flexed  and  extended  with  violent  shock-like 
contractions,  the  facial  and  eye  muscles  twitch,  saliva  collects  in 
the  mouth,  and  as  the  tongue  is  often  bitten,  it  becomes 
stained  with  blood.  The  moveiaents  are  sometimes  so  violent 
that  the  patient  is  thrown  about  the  bed  or  floor,  and  occasion- 
ally a  limb  is  dislocated,  usually  the  shoulder.  The  urine  often, 
and  the  faeces  occasionally,  are  passed.  The  temperature  is 
raised  V  to  1°  F.,  rarely  more.  The  pulse,  feeble  at  first,  becomes 
frequent  and  tense,  and  then,  as  the  attack  subsides,  becomes 
feeble  again.  The  clonic  spasm  lasts  one-half  to  one  or  two  min- 
utes. It  subsides  gradually,  and  the  patient  sinks  into  a  stupor, 
from  w^hich  he  can  be  roused  with  difficulty.  This  stupor  is  suc- 
ceeded by  a  heavy  sleep  of  several  hours  and  a  feeling  of  hebetude 
which  lasts  all  day.  Vomiting  sometimes  occurs  as  a  terminal 
symptom.  Immediately  after  the  attack  there  is  a  temporary 
exhaustive  paralysis,  with  loss  of  knee  jerk.  The  pui)ils  contract 
again  and  often  oscillate.^  There  may  be  a  slight  amount  of 
transient  albuminuria  or  glycosuria.  The  earthy  phosphates 
are  found  increased;  urea  is  not.  There  is  a  distinct  lessening  of 
haemoglobin  in  the  blood  (Fere)  and  of  haematoblasts.  Sometimes 
the  attack  is  followed  by  others,  and  for  hours  the  patient  passes 
from  one  convulsion  into  another.  This  condition  is  called  status 
epilepticus.  It  usually  la:,ts  less  than  twelve  hours,  but  may  last 
for  one  or  more  days  and  until  finally  death  occurs  from  exhaus- 
tion.    It  only  develops  in  the  severer  types. 

Symptoms  of  the  Minor  Attacks.— In  the  minor  attacks  (petit 
mal)  the  patient  suddenly  stops  in  anything  in  which  he  is  en- 
gaged, the  features  become  fixed,  the  eyes  open,  the  face  is  pale, 
the  pupils  dilated,  often  slight  twitching  of  the  facial  muscles  or 
of  the  limbs  occurs,  and  consciousness  is  lost.  In  a  few  seconds 
the  attack  is  over,  and  the  patient,  who  does  not  fall,  resumes  his 
work  or  conversation,  being  unconscious  of  what  has  occurred, 
except  that  he  has  had  a  "  spell."  Often  there  is  a  warning  sen- 
sation or  aura.  This  is  felt  as  giddiness,  sense  of  fear,  numb  sen- 
sations of  the  extremities,  flashes  of  light  or  blindness,  or  choking 
sensations.  There  may  be  a  cry  uttered.  The  minor  attacks  are 
in  rarer  cases  accompanied  with  sudden  forced  movements;  the 
patient  runs  a  few  steps,  or  turns  round  or  makes  some  automatic 
movements.     This  is  called  yrocmrsiiie  epilepsy. 

Symptoms  of  the  Psychical  Attacks.— Sometimes  the  minor  at- 
tacks are  followed  by  outbursts  of  maniacal  excitement  or  by 
sudden  violent  automatic  movements,  and  in  these  states  the 


EPILEPSY.  407 

patient  may  commit  crimes  of  violence.  In  rare  cases  the  patient 
passes  into  a  somnambulic  state,  during  which  he  performs  ac- 
customed acts,  such  as  driving  and  walking,  automatically  and 
naturally  (somnambulic  epilepsy).  This  form  of  epilepsy  may 
come  on  without  a  preliminary  minor  attack,  and  then  it  is  to  be 
considered  a  "  psychical  epileptic  equivalent.'" 

Minor  attacks  may  end  in  convulsions  of  a  co-ordinate  type  in 
which  the  patient  jumps,  kicks,  throws  the  arms  about  as  in 
hysterical  attacks.     These  are  called  hysteroid  convulsions. 

The  seizure  may  consist  of  only  a  short  tonic  stage  and  a  few 
twitchings  of  the  limbs,  the  whole  lasting  but  a  few  seconds. 
This  is  called  an  abortive  attack.  Under  the  influence  of  medi- 
cation, the  severe  seizures  are  often  reduced  to  abortive  forms. 

Jaoksonian  or  partial  e%)ilepsy  is  a  form  of  the  disease  char- 
acterized by  convulsive  attacks  affecting  only  a  single  group  of 
muscles  or  a  limb,  and  generally  not  accompanied  by  loss  of  con- 
sciousness. Jacksonian  epilepsy  is  always  symptomatic  of  some 
focal  lesion  afTecting  the  cortical  motor  area  of  the  brain.  This 
may  be  a  tumor,  inflammation,  or  injury.  This  form  of  seizure 
is  particularly  significant  of  a  slowly  growing  brain  tumor  or 
syphilis. 

The  aura  usuall}^  consists  of  a  sensation  of  numbness,  prick 
ling,  or  of  a  breeze  beginning  in  the  hand  or  leg  and  passing  up 
to  the  head,  when  consciousness  is  lost.  Still  oftener  there  is  a 
peculiar  sensation  starting  in  the  epigastrium  and  passing  up- 
ward. More  rarely  there  are  special  sense  aurse  such  as  flashes 
of  light,  noises,  or  voices,  and  peculiar  tastes  or  smells.  Besides 
these  there  occur  feelings  of  giddiness,  dreamy  states,  peculiar 
sensations  in  the  head,  and  indescribable  general  sensations. 

The  aurse  may  be  divided  into 

Visceral — epigastric,  laryngeal,  cardiac.  : 

Cutaneous  sensations. 

Special  senses — flashes  of  light,  etc. 

Psychical — emotions,  dreamy  states,  etc. 

Cephalic— giddiness,  etc. 

The  aura  is  thought  to  indicate  the  seat  of  the  first  discharge 
of  nerve  force,  and  its  study  is  of  most  importance  in  connection 
with  symptomatic  epilepsies,  as  Avill  be  shown  later. 

Relative  frequency  of  the  different  kinds  of  attacks.  The 
severe  attacks  are  the  most  frequent,  next  come  combinations  of 
severe  and  minor  attacks,  and  next  minor  attacks  alone,  while  the 
psychical  forms  are  the  rarest. 

Frequency  of  the  Attacks.— The  severe  attacks  may  come  on 
only  once  or  twice  a  year,  and  this  commonly  occurs  during  the 
development  of  the  disease.  The  frequency  gradually  increases 
until  they  occur  every  month  or  two  or  three  times  a  month. 


408  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Sometimes  the  fits  occur  in  groups  of  four  or  five  every  month 
or  two.  In  very  bad  cases  convulsions  occur  every  day.  The 
petit  mal  attacks  are  more  frequent  and  usually  occur  daily. 

Time  of  Attacks. — The  moon  and  the  seasons  have  no  influence. 
More  attacks  occur  during  waking  hours  than  during  sleep; 
but  two- thirds  of  the  attacks  occur  between  8  a.m.  and  8  p.m. 
Many  patients  have  their  attacks  early  in  the  morning  just  after 
awaking  {matutinal  epilepsy).  Many  attacks  occur  betAveen  3 
and  5  a.m.,  when  the  temperature  of  the  body  and  the  vital  powers 
are  at  the  lowest.  Practically  no  epileptic  attacks  occur  between 
11  A.M.  and  12  M.  (only  3  in  1,985— Fere). 

State  of  Patient  Between  Attacks. — Epileptic  patients  often 
feel  better  for  a  time  after  the  convulsion  is  over.  They  not 
rarely  suffer  from  severe  neuralgic  headaches;  the  appetite  is 
capricious,  often  in  children  it  is  voracious,  but  in  older  cases 
their  may  be  anorexia ;  the  bowels  are  usually  constipated ;  the 
pulse  is  small,  soft,  and  frequent. 

3Iental  Condition. — A  gradual  mental  deterioration  occurs  in 
the  great  majority  of  epileptics;  but  it  is  slight  in  some  and  not 
very  great  in  others.  It  shows  itself  by  feebleness  of  memory, 
irritability  of  temper,  selfishness,  incapacity  to  concentrate  the 
mind  or  to  carry  out  a  purpose.  In  children  great  mischievous- 
ness  and  lack  of  moral  sense,  with  vicious  impulses,  may  appear. 
The  mental  deterioration  is  dependent  on  those  underlying  fac- 
tors which  cause  the  disease.  It  is  apparently  in  some  cases  due 
to  the  excessive  number  of  the  fits.  This  is  not  necessarily  the 
case,  nor  is  it  generally  true  that  it  occurs  more  often  \vith  petit 
mal.  It  is  more  marked  in  cases  beginning  very  early  in  life,  but 
this  is  only  true  when  there  are  decided  marks  of  physical  and 
mental  degeneration  present.  A  certain  rather  small  percentage 
of  epileptics  become  either  demented  or  insane.  True  epilepsy  is 
not  compatible  with  extraordinary  intellectual  endowments. 
Caesar,  ^S^apoleon,  Peter  the  Great,  and  other  geniuses  may  have 
had  some  symptomatic  fits,  but  not  idiopathic  epilepsy. 

Physical  Condition. — Epileptics  are  rather  undersized  and  of 
not  very  robust  constitution  (Fere).  They  always  present  some 
of  the  marks  of  degeneration,  physical,  physiological,  or  mental. 
Such  marks  or  stigmata  are  about  ten  times  more  frequent  than 
in  healthy  persons.  The  physical  stigmata  are  (Fere)  short 
stature,  cranial  asymmetry  (in  71^),  short  parietal  or  frontal  arc, 
and  triangular  skull;  in  women  high  prominent  forehead;  bad 
teeth  badly  placed,  high  jDalatal  arch;  facial  asymmetry;  promi- 
nence of  occiput  and  lemurian  hypophisis;  differences  in  color, 
size,  position,  and  shape  of  pupils;  astigmatism  (in  75^  cases); 
badly  shaped  and  placed  ears;  misplaced  crown  of  scalp;  low 
vital  capacity ;  small  genitals,  atrophic  uterus;  greater  develop- 


EPILEPSY. 


409 


ment  of  left  side;  long  fingers.  Cranial  deformities  of  pro- 
nounced type  occur  in  epileptics  associated  with  idiocy,  hemi- 
plegia, and  brain  defects  of  early  origin.  Sometimes,  apparently 
from  a  premature  ossification  of  sutures,  there  are  the  peculiar 
shapes  of  the  skull  known  as  scaphocephaly,  or  steeple  skull,  and 
plagiocephaly,  or  obliquely  deformed  skull. 

The  physiological  marks  of  deterioration  are  a  lessened  mus- 
cular strength  (as  35  to  50),  habit  choreas,  a  rather  imperfect  eye 
with  excessive  amount  of  astigmatism  and  functional  mus- 
cular weakness.  There  is  a  lessened  vital  capacity,  weak  and 
slow  digestion,  and  sexual  atrophy  or  irritability.  The  excretion 
of  phosphoric  acid  is  below  normal  as  compared  with  urea. 


Fig.  190.— Diffuse  Neuroglia  Sclerosis     Fig.  191.— Same,  Enlarged  (Chaslin). 
OF  the  Cortex  in  Epilepsy. 


The  psychical  stigmata  are  mental  feebleness,  moral  insensi- 
bility, irritability,  wayward  and  vicious  inpulses,  lack  of  will 
power,  and  sexual  aberrations. 

Pathology. — The  body  of  the  epileptic  shows  sometimes  skin 
eruptions  and  ulcers,  the  result  of  treatment.  There  are  often 
evidences  of  local  injuries  and  fractures  due  to  falls.  The  organs 
may  show  vices  of  conformation.  The  uterus  is  frequently  in- 
fantile or  sharply  flexed.  Deformation  of  the  occipital  bone  or 
the  atlas  so  as  to  produce  narrowing  of  the  upper  spinal  canal 
has  been  noticed.  The  brain  may  be  unduly  large  or  small,  but 
there  is  nothing  constant  in  this,  nor  is  there  an  abnormal  differ- 
ence in  the  weight  of  the  two  hemispheres.  The  convolutions 
show  many  anomalies,  but  there  is  in  them  nothing  specific.  On 
the  whole  the  convolutional  type  is  a  simple  one.  The  patholog- 
ical change  found  most  constantly  in  epilepsy  is  an  induration  or 
sclerosis  (ghosis).  This  affects  the  cornu  ammonis  rather  often 
(4^  to  Wo),  more  rarely  the  olivary  bodies  or  cerebellum.    Besides 


410  DISEASES    OF  THE  NERVOUS   SYSTEM. 

this,  small  patches  of  induration  occur  in  the  gray  matter  in  vari- 
ous parts  of  the  cortex.  Chaslin  finds  a  diffuse  increase  of  neu- 
roglia tissue  throughout  the  brain,  more  marked  when  the  case  is 
older  (Fig.  191).  Others  have  found  an  increase  in  the  neuroglia 
cells  (Kingsbury).  In  old  cases  there  is  often  a  chronic  leptomen- 
ingitis, and  vascular  changes  due  to  the  frequent  congestions  of 
the  brain  take  place.  These  consist  in  varicose  and  fusiform  di- 
latation of  vessels,  with  evidence  of  small  hemorrhages.  Slight 
degenerative  changes  in  the  nerve  fibres  are  also  observed. 

Bevan  Lewis  finds  in  epileptics  with  insanity  a  fatty  de- 
generation of  the  nuclei  of  the  "angular  cells''  of  the  second 
layer  of  the  cortex.  In  the  severer  and  later  stages  of  the  dis- 
ease this  nuclear  degeneration  is  increased  so  that  vacuoles  are 
formed.  The  cells  of  the  deeper  layers  are  also  affected,  but  to  a 
less  extent.  The  change,  though  not  peculiar  to  epilepsy,  is 
more  extensive  and  pronounced  in  this  disease. 

To  sum  up:  The  anatomical  basis  of  idiopathic  epilepsy  con- 
sists in  a  nuclear  degeneration  and  later  a  vacuolation  of  the  cor- 
tical cells,  beginning  and  most  pronounced  in  the  cells  of  the  sec- 
ond layer.  Also  a  proliferation  and  increase  in  the  neuroglia 
tissue,  this  occurring  most  markedly  in  various  islets  or  sj^ecial 
areas  of  the  cortex.  The  blood-vessels  and  connective  tissue  are 
involved  only  secondarily  and  later. 

Physiology. — The  epileptic  fits  are  due  to  sudden  discharges  of 
nerve  force.  The  seat  of  the  discharge  is  the  cortex  of  the  brain. 
The  discharging  cells  are,  in  the  severe  seizures,  the  large  motor 
cells,  the  function  of  which  is  to  store  up  and  discharge  nerve 
force.  They  are  under  control  of  the  sensory  cells  (angular  cells) 
of  the  second  layer,  which  have  an  inhibitory  power.  These 
being  diseased  their  control  is  weakened  and  the  motor  cells 
"  explode ''  iDeriodically.  In  sensory  and  psychical  epilepsy  the 
same  mechanism  exists.  The  more  highly  organized  cells  with 
large  nuclei  of  the  second  layer  are  congenitally  or  otherwise 
Aveak  and  diseased,  the  cells  below  them  are  not  maintained  in 
stable  equilibrium  and  hence  iDeriodically  break  down  and  "dis- 
charge." 

The  diagnosis  is  based  on  the  character  of  the  attacks  and 
has  to  be  made  from  hysterical  and  various  toxic  and  sympto- 
matic convulsions. 

The  aura,  the  scream,  the  quick  loss  of  consciousness,  the  di- 
lated pupils,  the  tonic  convulsion,  the  bitten  tongue,  the  emptied 
bladder,  are  all  characteristic.  The  hysterical  patient  sometimes, 
but  rarely,  loses  consciousness,  the  epileptic  almost  always.  Hys- 
terical patients  do  not  hurt  themselves  in  falling  or  bite  their 
tongue,  and  their  muscular  movements,  while  irregular  and  vio- 
lent in  character,  are  yet  co-ordinate,  ^.e.,  they  throw  themselves 


EPILEPSY.  411 

about,  kick,  strike,  etc.  Their  attacks  often  are  produced  by 
emotion  and  are  ended  by  some  powerful  mental  or  physical 
impression.  The  slight  rise  of  temperature  in  epileptics  rarely 
occurs  in  hysterics.  Petit  mal  and  epileptic  vertigo  are  distin- 
guished by  the  sudden  lapse  of  consciousness  and  by  the  sudden 
pallor  and  fixation  of  the  eyes,  dilatation  of  the  pupils,  and 
slight  twitchings  of  the  face.  Nocturnal  convulsions  are  usually 
epileptic. 

Eclampsia,  or  acute  symptomatic  and  reflex  convulsions,  can- 
not always  be  distinguished  from  epilepsy.  The  history  of  the 
case,  the  irregular  and  often  prolonged  character  of  the  fit,  may 
enable  one  to  make  the  diagnosis. 

Course  and  Prognosis. — Epilepsy  shortens  life  to  some  extent; 
most  cases  do  not  live  beyond  the  age  of  forty  or  fifty.  About  ten 
per  cent  become  demented  or  insane.  Five  or  ten  per  cent  get 
well.  The  remainder  reach  a  certain  stage  of  severity  in  their 
disease  and  continue  in  it  for  years.  This  severity  depends  on 
the  treatment,  the  nature  of  the  attacks,  and  the  extent  of  de- 
generation which  the  organism  shows.  While  unquestionably 
treatment  cures  or  sui^presses  the  disease  in  some  cases,  it  disap- 
pears spontaneously  in  others.  The  prognosis  of  petit  mal  is 
worse  than  that  of  grand  mal ;  that  of  the  two  combined  is  worse 
still,  yet  not  hopeless.  The  psychical  form  of  epilepsy  is  the  least 
amenable  to  treatment.  Epileptic  insanity  and  dementia  are  in- 
curable. Death  occurs  rarely  in  the  attacks  except  in  terminal 
stages.     Yet  the  status  epilepticus  is  always  a  source  of  danger. 

Epileptics  are  said  rather  frequently  to  suffer  from  phthisis. 
This  is,  however,  a  matter  of  infection  and  can  be  prevented.  It 
should  be  remembered  that  epileptics  who  have  only  a  moderate 
number  of  attacks,  six  to  fifteen  yearly,  can  get  along  comfort- 
ably for  years,  doing  their  work  and  enjoying  a  fair  share  of  the 
duties  and  pleasures  of  life.  Finally,  the  following  prognostic 
rules  may  be  laid  down  :  The  prognosis  is  better  in  males,  better  if 
there  is  a  hereditary  history,  better  if  the  fits  are  nocturnal  or 
diurnal  alone,  better  in  grand  mal,  better  if  fits  occur  infrequently, 
better  if  they  begin  after  twenty,  and  better  if  due  to  extrinsic 
causes.  The  prognosis  is  very  bad  in  post-hemiplegic  epilepsy 
and  epilepsy  due  to  organic  disease. 

Treatment.— The  first  and  essential  rule  of  treatment  is  to  take 
cases  early  and  treat  them  vigorously  from  the  start.  Children 
who  have  had  a  few  convulsions  during  the  first  three  to  five 
years  of  life  should  be  treated  as  if  they  might  develop  epilepsy 
between  the  ages  of  ten  and  fifteen  or  earlier.  The  recurrence 
of  a  fit  betw^een  the  ages  of  five  and  ten  should  excite  appre- 
hension and  call  for  the  most  diligent  treatment.  Another  rule 
is  that  when  epilepsy  is  recognized  in  children  the  case  should  be 


412  DISEASES   OF  THE   NERVOUS   SYSTEM. 

treated  constantly  for  at  least  three  years  after  all  attacks  have 
ceased. 

Conditntional  Treatment.— A\on^  with  the  evolution  of  epi- 
lepsy there  is  probably  a  progressive  diffuse  neuroglia  sclerosis  of 
the  brain.  Whether  this  is  primary  or  secondary,  it  is  at  least 
proper  to  use  those  measures  which  apparently  affect  this  neu- 
roglia proliferation.  ]S^itrate  of  silver  and  arsenic  and  perhaps 
iodide  of  potassium  are  drugs  which  we  have  good  reason  for  be- 
heving  affect  this.  Hence  I  advise  that  all  epileptics  as  the 
basal  medication  should  be  given  courses  of  these  drugs. 

Besides  this,  we  should  use  measures  that  increase  vasomotor 
tone  and  strengthen  and  steady  the  circulation.  Nothing  does 
this  better  than  water.  Epileptics  should  be  given  showers, 
douches,  cold  sponge-baths,  or  wet-packs  according  to  their  needs 
and  opportunities.  They  should  also  drink  water  freely.  Again, 
the  nervous  system  is  greatly  steadied  and  quieted  by  mental 
occupation  that  interests  one.  Nothing  is  more  unfortunate  than 
the  idleness  often  enforced  on  epileptics.  1  have  seen  the  dis- 
ease absolutely  checked  by  having  a  boy  learn  a  trade  that  he 
liked. 

The  next  most  important  indication  is  diet.  In  petit  mal  par- 
ticularly an  absolutely  noh-irritating  diet,  such  as  milk,  meat, 
and  bread,  will  quickly  lessen  or  stop  the  attacks.  Meats  can  be 
taken  in  moderation  if  eaten  slowly.  As  a  rule  it  is  a  little  safer 
to  keep  meat  out  of  children's  diet  for  a  time;  but  in  adults  it  is 
not  necessary. 

Removal  of  irritating  causes.  Malaria  if  present  promotes  the 
con^^lsive  tendency ;  so  also  do  lead  and  alcohol ;  tobacco  does 
not  do  this,  but  its  use  is  better  stopped,  as  it  is  liable  to  weaken 
vascular  tone  and  impair  digestion.  Syphilis  causes  epilepsy  only 
through  producing  organic  changes. 

The  rheumatic,  gouty,  and  so-called  tubercular  diatheses  do 
not  stand  in  any  close  relation  to  epilepsy.  The  condition  known 
as  lithaemia,  however,  in  which  there  is  insufficient  oxidation 
and  excretion  of  products  of  tissue  waste,  needs  attention.  Hence 
the  use  of  bicarbonate  of  potash,  the  alkaline  mineral  waters,  and 
a  restricted  diet  is  not  rarely  indicated. 

The  importance  of  reflex  irritations  has  been  much  overesti- 
mated. Still  they  must  be  considered.  The  most  serious  are 
those  arising  from  the  gastro-intestinal  tract,  the  sexual  organs, 
and  the  eyes.  Phimosis  if  present  must  be  relieved,  and  mastur- 
bation or  sexual  excesses  stopped  if  possible.  It  is  admitted 
now  that  removal  of  the  ovaries,  even  if  diseased,  never  cures 
true  epilepsy,  though  it  may  help  hysterical  convulsions. 

Astigmatism  and  hypernietropia  should  be  corrected;  also 
ocular  insufficiencies  if  these  are  pronounced. 


EPILEPSY.  413 

Proper  attention  to  the-  frequent  constipation  and  dyspepsia 
is  of  course  necessary.  The  use  of  hot  water  is  often  serviceable, 
a  glass  being  sipped  slowly  before  the  niorning  and  evening  meals! 
This  helps  also  to  carry  off  the  bromides  and  wash  out  the  system 
generally.  To  still  further  promote  this,  a  purge  should  be  given 
every  fortnight  or  month.  Out-door  life  and  active  physical 
exercise  are  indorsed  by  Hippocrates.  They  do  not  have  any 
specific  influence  unless  associated  with  some  employment. 

Specific  treatment.  The  drugs  which  have  obtained  and  held 
a  reputation  as  anti-epileptics  are  not  numerous.  They  are  the 
bromides,  chloral,  chloral-amide,  belladonna,  zinc,  nitro-glycerin 
antipyrin.  Of  less  value  are  digitahs,  cannabis  indica,  borax, 
valerian,  and  ergot.  As  adjuvant  drugs  we  have  quinine,  strych- 
nia, iron,  the  phosphates,  arsenic,  silver,  the  alkalies  and  iodides. 
The  most  valuable  of  the  specific  drugs  are  the  bromides. 

All  bromides  act  alike  in  this  disease.  If  one  does  not  cure 
another  will  not.  Occasionally,  changing  or  mixing  reduces  the 
attacks  for  a  time  and  benefits  the  stomach.  The  best  bro- 
mides are  those  of  potassium,  sodium,  strontium,  ammonium,  and 
hydrogen  (hydrobromic  acid). 

Bromide  of  jjotassium  is  the  most  trustworthy.  Bromide  of 
sodium  is  more  agreeable  to  the  taste,  less  irritating  to  the  stom- 
ach and  milder  in  its  effects,  but  is  eventually  just  as  depressing 
as  other  forms.  Bromide  of  ammonium  has  a  brief  stimulant 
effect  on  the  circulation.  Bromide  of  strontium  has  no  advan- 
tages that  I  can  discover.     Bromide  of  gold  is  of  no  use. 

Hydrobromic  acid  is  useful  in  those  cases  in  which  there  are 
indigestion  and  phosphaturia  and  an  alkali  is  contra-indicated. 
It  produces  acne  less  readily  than  the  alkaline  bromides. 

Bromides  should  be  given  in  daily  doses  of  3  i.,  increased  grad- 
ually until  the  attacks  are  suppressed  or  the  dose  reaches  3  iv.  to 
§  i.  daily.  Few  patients  can  tolerate  more  than  this  latter  dose. 
Thorough  bromidization  should  be  always  tried  if  necessary  to 
stop  the  fits,  and  it  may  be  occasionally  repeated.  But  bromidi- 
zation is  sometimes  injurious,  ev^en  making  the  disease  worse, 
and  it  must  always  be  employed  with  caution.  When  the  fits  are 
suppressed  the  bromides  should  be  reduced,  but  never  entirely 
stopped  for  at  least  two  years  after  the  last  fit.  In  most  cases, 
and  especially  in  nocturnal  epilepsy,  an  extra  .large  dose  of 
bromide  or  bromide  and  chloral  should  be  given  at  night.  It  is 
very  important  that  the  bromides  should  be  chemically  pure 
(most  samples  are  not),  that  their  use  should  be  continued  a  very 
long  time,  and  that  their  depressing  effects  should  be  offset  by 
tonics  and  all  possible  roborant  measures. 

Bromides  lessen  the  fits  in  from  eighty  to  eighty-five  per  cent 
of  cases.     They  do  no  good  or  do  actual  harm,  as  regards  fre- 


414  DISEASES  OF  THE  NERVOUS  SYSTEM. 

quency  of  attacks,  in  from  five  to  ten  per  cent  of  cases.  Bro- 
mides do  no  actual  good  to  the  patient  in  a  much  larger  propor- 
tion of  cases. 

To  prevent  bromide  acne,  arsenic,  calcium  sulphide,  baths, 
and  diuretics  are  the  best  measures. 

To  prevent  bromidization,  one  should  adopt  all  possible  robo- 
rant  measures ;  use  salt-water  baths  and  regular  physical  exercise, 
give  black  cofTee,  caffeine,  cocaine,  mineral  acids,  strychnine, 
bitter  tonics,  cod-liver  oil.  In  all  cases  the  patient  should  dilute 
the  drug,  preferably  with  carbonic-acid  water  or  Vichy,  in  the 
proportion  of  six  ounces  of  water  to  a  scruple  of  the  drug.  A  few 
drops  of  phosphoric  acid  may  be  added  to  this. 

The  continuous  administration  of  an  alkaline  bromide  in  an 
alkaline  water  sometimes  affects  'the  bladder,  and  then  the  bro- 
mide can  be  given  dissolved  in  hydrobromic  acid. 

The  best  substitutes  for  the  bromides,  when  these  do  no  good 
or  do  harm,  are  belladonna,  zinc,  strychnine,  glonoin,  borax,  and 
antipyrin. 

The  best  non-specific  adjuvants  (drugs)  to  the  bromides  are 
potassium  iodide  (in  syphilitic  epilepsy),  potassium  bicarbonate 
(in  lithsemic  and  rheumatic  states),  carbonate  of  ammonium,  the 
hyi^ophosphites,  arsenic,  iron,  and  quinine. 

The  best  sj^ecific  adjuvant  to  the  bromides,  as  Seguin  has 
shown,  is  chloral  hydrate.  By  adding  five  or  six  grains  of  this  to 
a  mixture  the  bromide  dose  can  be  reduced  one-half  and  the  fits 
still  be  controlled.  Chloral-amide  has  a  similar  effect.  Both 
these  drugs  will  sometimes  affect  the  eyes  and  stomach  unfavor- 
ably.    Children  bear  nearly  as  large  doses  of  bromide  as  adults. 

The  remedies  that  are  especially  useful  in  petit  mal  are,  after 
the  bromides,  bromide  of  camphor,  belladonna,  glonoin,  canna- 
bis indjca,  cod-liver  oil,  ergot,  counter-irritation  at  the  back  of 
the  neck,  and  cold  spinal  douches. 

For  epilepsy  in  children,  besides  the  bromides  it  is  sometimes 
advisable  to  employ  milk  diet,  rest,  and  oxide  of  zinc. 

In  hemiplegic  and  in  Jacksonian  epilepsy  the  actual  cautery 
applied  over  the  scalp  is  beneficial.  For  nocturnal  epilepsy  one 
may  increase  the  dose  of  bromide  at  night  and  add  chloral  or 
digitalis.  Strychnine  is  sometimes  useful.  Raising  the  head  of 
the  bed  or  making  the  patient  sleep  in  a  chair  at  night  are  meas- 
ures that  may  be  tried. 

For  hysterical  and  erethitic  cases,  with  or  in  place  of  bromides 
give  a  diet  of  milk  and  vegetables,  and  try  turpentine,  valerian, 
or  zinc.     Belladonna  is  usually  contra-indicated. 

Counter-irritation  by  means  of  blisters,  issues,  and  setons  at 
the  back  of  the  neck  is  of  doubtful  value. 

For  the  status  epilepticus  give  large  enemata  of  chloral  and 


EPILEPSY.  415 

use  emetics  and  purges.  Venesection  is  often  efficacious,  morphine 
is  dangerous,  ciiloroform  is  only  palliative,  and  nitrite  of  amyl 
is  of  little  value. 

To  prevent  impending  attacks  the  best  remedy  is  nitrite  of 
amyl,  which  may  be  carried  in  a  phial  filled  with  cotton.  Inhala- 
tion of  chloroform  or  ammonia,  the  internal  administration  of 
ammonia,  spirits  of  lavender,  or  alcohol,  a  sternutatory,  and 
pressure  on  the  carotids— all  are  measures  which  sometimes  stop 
the  attack. 

Alterative  and  habit-breaking  drugs,  such  as  mercury,  iodide  of 
potassium,  arsenic,  and  antimony,  are  useful  in  epilepsy,  especially 
in  acquired  forms  due  to  lead,  alcohol,  and  syphilis.  Bromides 
stop  the  fits  oftener  if  given  early  in  the  disease,  if  given  to  young 
children,  and  if  given  in  cases  that  develop  after  twenty-one. 

Injuries  to  the  head  which  have  caused  a  fracture  or  a  con- 
tusion of  the  brain  are  the  most  frequent  traumatic  irritants. 
Whenever  epilepsy  can  be  distinctly  traced  to  a  blow  on  the 
head  the  question  of  trephining  should  be  brought  up.  If  there 
is  a  history  of  fracture  or  present  evidence  of  fracture  or  even 
evidence  of  severe  head  injury,  trephining  is  justifiable.  The 
more  marked  the  evidence  of  a  degenerative  constitution  and  the 
less  marked  the  evidence  of  real  brain  injury,  the  less  hopeful 
the  prognosis.  On  the  whole,  surgery  can  do  little  for  acquired 
and  nothing  for  idioj)athic  epilepsy. 


CHAPTER  XXIL 

HYSTERIA. 

Hysteria  is  a  chronic  functional  disorder  characterized  by 
nervous  crises  of  an  emotional,  convulsive,  or  other  nature  and  by 
an  interparoxysmal  state  in  which  certain  marks  or  stigmata  are 
present.  Hysteria  is  essentially  a  psychosis,  and  the  dominant 
symptoms  are  attributable  to  disorder  of  the  cortical  areas  of  the 
brain.  Its  components  are  the  paroxysms,  or  "  crises "  as  they 
are  called,  on  the  one  hand,  and  the  peculiar  symptoms  of  an 
interparoxysmal  state  on  the  other  hand.  The  disease  is  to  be 
regarded  as  a  definite  one,  having  a  certain,  as  yet  unknown, 
pathological  basis  underlying  it.  The  use  of  the  word  should  be 
much  more  restricted  and  definite  than  has  hitherto  been  the 
fashion.  There  are  two  forms  of  the  disease,  hysteria  major  and 
hysteria  minor. 

Etiology. — Of  the  predisposing  causes  heredity  is  the  most 
important.  In  about  seventy-five  per  cent  there  is  a  history  of 
hysteria  or  some  neurosis  or  psychosis  in  the  i)arents.  The  disease 
is  transmitted  more  often  by  the  mother.  Heredity  is  particu- 
larly apt  to  be  important  in  the  hysteria  of  children ;  it  is  a  much 
smaller  factor  in  hysteria  of  adult  males.  A  hereditary  history 
of  rheumatism,  gout,  and  tuberculosis  is  of  very  doubtful  im- 
portance. Hysteria  is  a  disease  of  early  adult  life,  most  cases 
occurring  between  the  ages  of  from  fifteen  to  twenty-five  in 
females ;  it  occurs  later  in  males.  Hysteria  attacks  children  be- 
tween the  ages  of  eight  and  fifteen,  chiefly  between  eleven  and 
fourteen.  The  disease  affects  Avomen  more  than  men  in  the  pro- 
portion of  four  to  one,  varying  much  with  race,  climate,  and 
occupation.  Hysteria  occurs  in  all  classes  of  life,  but  rather  less 
frequently  in  the  middle  classes  than  among  the  poor  and  the 
very  rich.  Male  hysteria  is  more  frequent  in  the  poorer  classes 
who  are  subjected  to  the  exciting  influences  of  alcoholism,  pov- 
erty, injuries,  etc.  Hysteria  is  certainly  much  less  frequent  in  its 
severer  forms  in  this  country  than  in  some  parts  of  Europe,  par- 
ticularly France.  In  my  experience  it  is  much  less  frequent  than 
epilepsy  in  the  northern  and  eastern  parts  of  this  country,  It 
occurs,  however,  quite  frequently  in  the  negroes  and  also  in  the 
Latin  races  of  this  country.  Bad  methods  of  education  and  bad 
family  training  undoubtedly  tend  to  promote  the  development  of 
the  disease. 


HYSTERIA.  417 

The  most  important  single  exciting  factor  is  powerful  emotion, 
particularly  fear.  Other  emotions  of  an  allied  character— excite- 
ment, sorrow,  anxiety— may  bring  on  attacks.  The  disease  can  be 
developed  by  imitation.  Injuries  combined  usually  with  mental 
shock  are  fruitful  causes  of  producing  hysteria.  The  infectious 
fevers,  syphilis,  diffuse  hemorrhages,  the  poisons— lead,  alcohol, 
mercury,  and  tobacco— the  administration  of  ether,  mental  and 
bodily  and  sexual  excesses  are  all  important  agents  in  developing 
the  disease, 

SynuJtoms.— The  symptoms  of  hysteria  are  best  described 
under  two  general  heads— first,  those  of  hysteria  minor  or  the 
hysterical  condition,  and,  second,  those  of  hysteria  major. 

1.  Hysteria  minor  is  characterized  by  the  interparoxysmal  con- 
dition of  emotional  weakness,  nervousness,  hypersesthesia  and 
pains,  and  by  crises  of  an  emotional  character.  In  hysteria  minor 
there  are  no  permanent  objective  marks  like  anaesthesia  and 
paralysis,  and  no  decided  convulsive  seizures.  The  patient,  who 
is  almost  always  a  girl  or  young  woman,  gradually  develops 
an  undue  sensitiveness,  the  mind  is  depressed,  and  she  gets  easily 
alarmed.  She  has  feelings  of  nervousness  and  lacks  control  over 
the  emotions,  she  laughs  and  cries  very  easily  and  yields  to  every 
impulse.  She  suffers  from  headaches  which  are  usually  vertical 
and  often  severe  and  chronic,  and  from  spinal  pains.  She  sleeps 
as  a  rule  rather  badly  and  often  has  disagreeable  dreams.  She 
has,  under  any  little  excitement,  sensations  of  tickling,  fulness 
or  choking  in  the  throat,  forming  the  condition  known  as  globus. 
Excitement  also  brings  on  attacks  of  trembling  or  chilly  feelings 
which  come  and  go.  There  is  more  rarely  a  considerable  amount 
of  vasomotor  instability,  as  shown  by  flushings  and  by  coldness 
of  the  extremities. 

She  has  with  more  or  less  frequency  distinct  crises  of  an  emo- 
tional character,  during  which  she  laughs  or  cries  without  ap- 
parent cause,  or  at  least  to  an  extent  beyond  her  control.  She 
may  have  attacks  of  vomiting  or  headache,  or  of  intense  mental 
excitement  amounting  almost  to  delirium.  In  some  cases  the 
patient  has  somnambulic  attacks  at  night,  or  she  may  have  under 
a  little  excitement  attacks  of  cerebral  automatism  during  which 
she  involuntarily  does  things  that  she  is  entirely  unconscious 
of  when  she  comes  out  of  the  attack.  The  crises  are  followed  by 
a  copious  discharge  of  very  light  urine.  Hysteria  minor  is  closely 
allied  to  a  condition  of  neurasthenia  or  of  simple  nervousness.  It 
is  associated  with  neurasthenia  oftentimes,  and  is  to  be  distin- 
guished from  it  chiefly  by  the  peculiar  psychical  state,  the  hyper- 
^esthesia,  and  the  crises  which  have  been  described.  Even  in 
hysteria  minor  there  is  a  degree  of  that  peculiar  mental  condi- 
tion which  will  be  described  later  and  which  is  known  as  sug- 
27 


418  DISEASES   OF   THE   NERVOUS   SYSTEM. 

gestibility.  Hysteria  minor  is  a  disease  which  belongs  especially 
to  childhood  and  early  womanhood.  It  is  very  liable  to  become 
ameliorated  and  disappear  a  little  later  in  life  or  under  the  in- 
fluence of  proper  treatment,  but  it  may  continue  or  pass  into  the 
major  form. 

2.  Hysteria  major  is  characterized  by  interparoxysmal  mani- 
festations of  anaesthesia,  paralyses,  contractures,  tremors,  pecul- 
iar mental  conditions,  and  by  paroxysms  of  an  emotional,  con- 
vulsive, or  other  serious  nature.  Hysteria  major  is  what  is 
usually  meant  when  one  si)eaks  of  hysteria;  it  includes  also 
hystero-epilepsy.  The  onset  may  be  gradual,  but  not  infre- 
quently it  follows  some  shock,  the  first  symptom  being  a  convul- 
sion, a  paralysis,  or  some  emotional  outburst- 

The  symjytoms  of  the  crises  are  the  most  striking  and  will  be 
described  first.  The  most  common  of  the  paroxysms  of  hystei'ia 
are  emotional  outbursts  of  crying  or  laughing ;  after  this  come 
motor  disturbances  in  the  shape  of  convulsions  of  various  types. 
Besides  this  we  have  attacks  of  severe  i^ain,  forming  neuralgic 
crises ;  attacks  of  nausea,  gastralgia,  and  vomiting,  forming  gas- 
tric crises;  much  more  rarely  there  are  prolonged  attacks  of 
hysterical  coughing,  hiccoughing,  sneezing,  or  rapid  breathing. 
The  hysterical  seizure  may  also  take  the  form  of  attacks  of  trance 
and  lethargy,  catalepsy,  amnesia,  and  cerebral  automatism. 

The  emotional  crises  are  characterized  by  ajDpearing  without 
any  good  cause;  the  patient  laughs  Avithout  reason,  and  the 
laughing  continues  and  is  quite  beyond  her  joower  of  control. 
In  the  same  way,  and  rather  more  frequently,  crying  attacks  or 
attacks  of  furious  anger  and  excitement  come  on.  Associated 
with  these  outbursts  there  is  almost  always  a  peculiar  sensation 
of  something  in  the  throat.  It  is  described  sometimes  as  being  a 
ball  or  pressure  or  a  squeezing  sensation.  It  is  called  hysterical 
globus,  and  is  due  usually  to  a  paresthesia  of  the  nerves  of  the 
throat  and  larynx,  but  occasionally  there  «ris  also  a  muscular 
spasm  of  those  parts.  Following  the  crises  there  is  a  profuse 
discharge  of  pale,  limpid  urine. 

Hysterical  convulsions  have  two  rather  Avell-defined  types. 
One  of  them  is  that  which  comes  on  also  in  hysteria  minor  and 
is  the  ordinary  form  of  hysterical  convulsions;  the  other  is  a 
much  more  severe  disturbance  in  every  way  and  is  known  as  a 
hystero-epileptic  or  hysteroid  attack.  In  the  hysterical  convul- 
sion the  patient,  under  the  influence  of  some  excitement,  in- 
jury, or  acute  gastric  disturbance,  rather  suddenly  falls  down  and 
begins  to  go  through  various  irregular  movements  of  the  body, 
such  as  thrashinu-  with  the  arms,  kicking  with  the  legs,  throwing 
the  head  from  side  to  side,  rolling  about  on  the  bed  or  floor.  In 
the  more  distinctively  convulsive  seizure  the  hands  and  arms 


HYSTERIA.  419 

and  fingers  are  flexed,  the  legs  and  feet  are  extended,  the  eyes 
are  generally  closed,  the  eyeballs  often  converged  or  moved  about 
irregularly,  the  pupils  dilated.  There  is  some  lessening  of  sensa- 
tion over  the  body  and  of  the  conjunctivae.  The  patient  often 
utters  noises  or  screams  at  intervals.  She  may  bite  her  lips,  but 
does  not  bite  the  tongue,  nor  does  she  ever  hurt  herself  in  her  va- 
rious contortions.  The  attack  may  last  for  half  an  hour  to  several 
hours,  unless  some  measured  are  taken  to  break  it  up.  In  other 
forms  of  hysterical  convulsion  there  is  simply  a  general  shaking 
or  trepidation  of  the  body  as  though  the  patient  had  a  chill;  in 
other  cases  again  the  main  type  of  movement  is  that  of  opistho- 
tonos, the  patient  rising  up  upon  the  head  and  heels  and  arching 
the  body  as  in  tetanus.  Again  the  attack  may  consist  simply  of  a 
little  rigidity  of  the  body,  or  of  a  series  of  rhythmical  movements 
of  the  head  or  trunk  or  limbs,  the  patient  sitting  up  and  oscillat- 
ing the  head  or  swaying  the  trunk  or  moving  the  arms,  uttering 
at  the  same  time  incoherent  words.  In  children  the  attacks  may 
be  associated  with  peculiar  noises  and  movements  in  imitation  of 
animals,  such  as  the  growling  of  a  dog  or  the  mewing  of  a  cat. 
This  condition  is  called  therio-mimicry.  In  some  instances  the 
attack  may  be  accompanied  or  may  end  in  a  condition  of  mental 
excitement  approaching  delirium.  The  patients  while  suffering 
from  these  seizures  generally  appreciate  what  is  going  on  about 
them,  and  will  often  res^^ond  to  some  stern  order  for  them  to  cease 
or  will  be  brought  to  a  state  of  quietude  by  pressure  upon  some 
part  of  the  body  which  provokes  pain.  In  Avomen  in  particular, 
pressure  over  the  ov^aries  or  epigastrium  will  abort  the  attack; 
the  application  of  cold  water  or  an  emetic  will  do  the  same. 

The  Symptoms  of  the  Interparoxysmal  State.— Between  the 
crises  the  patient  may  be  in  a  fair  condition  of  general  health, 
but  usually  presents  certain  definite  chnmic  manifestations  of  the 
disease.  The  most  characteristic  are  sensory  symptoms,  paralyses, 
and  contractures. 

Sensory  symptoms.  These  consist  of  cutaneous  and  mucous 
hyperaBsthesia  and  anaesthesia  and  anaesthetic  disturbances  of 
the  special  senses.  Cutaneous  anaesthesia  occurs  in  three  forms : 
the  common  form  is  that  of  hemianaesthesia  involving  one-half 
of  the  body;  next  in  frequency  is  the  segmental  anaesthesia  in- 
volving an  arm  or  a  leg  or  part  of  the  face  or  head ;  rarest  of  all 
the  forms  is  a  disseminated  anaesthesia  occurring  in  the  form  of 
patches.  These  various  modes  of  distribution  are  shoAvn  in  the 
accompanying  figures.  The  anaesthesia  is  a  pain  anaesthesia 
chiefly.  The  tactile  and  thermic  sensations  are  less  markedly 
affected.  The  aucesthesia  is  in  some  rare  cases  transferable  by 
means  of  magnets  or  electrical  irritants  or  by  suggestion.  The 
anaesthesia  can  also  be  lessened  or  removed  temporarily  by  the 


420 


DISEASES   OF  THE  NERVOUS   SYSTEM. 


application  of  magnets  or  coins  or  pieces  of  metal.  For  example, 
if  a  silver  coin  is  fastened  upon  the  anaesthetic  area,  in  the  course 
of  a  few  minutes  or  a  few  hours  there  will  be  a  zone  of  normal 
sensation  under  and  around  the  coin.  Sometimes  the  tempera- 
ture of  the  skin  upon  the  anaesthetic  part  is  lowered  3°  or  4°  F., 
and  upon  pricking  the  skin  blood  does  not  flow.  The  anaesthesia 
is  oftener  upon  the  left  side  in  the  proportion  of  three  to  one. 
Hysterical  anaesthesias  are  not  accompanied  with  subjective  sen- 
sations like  organic  anaesthesias.  The  skin  reflex  is  usually  abol- 
ished. Anaesthesias  of  some  kind  occur  in  a  very  large  proportion 
of  chronic  forms  of  hysteria  major.     They  are  rare,  however,  in 


Fig.  192.— The  Three  Types  op  Distribution  of  Anesthesia  in  Hysteria  : 
Hemianesthesia,  iSEGMENTAL,  and  Disseminated.    Z,  Hysterogenic  zones. 


children,  and  are  rarer  in  women  than  in  men  in  the  author's  ex- 
perience. Anaesthesia  of  the  mucous  membranes  is  present  chiefly 
in  hemianaesthesia ;  it  then  involves  the  mucous  membrane  of  the 
mouth  and  throat,  and  to  a  less  extent  that  of  the  nose  and  glot- 
tis. Hemianaesthesia  is  usually  accompanied  with  some  hemi- 
plegia and  often  with  some  tremor.  Segmental  anaesthesia  is 
also  often  accompanied  with  some  degree  of  paralysis  of  the  part. 
Visual  anaesthesias.  One  of  the  most  common  of  the  perma- 
nent stigmata  of  hy.steria  is  an  anaesthetic  condition  of  the  retina. 
The  result  of  this  is  the  production  of  a  concentric  limitation  of 
the  visual  field  and  a  disturbance  in  the  color  sense.  Complete 
loss  of  this  sense  may  take  place  or  there  may  be  a  variation 
in  the  way  in  wdiich  the  colors  are  perceived.     There  may  be  also 


1 


J 


HYSTERIA. 


421 


a  distinct  diminution  in  the  acuity  of  vision  or  even  a  complete 
loss  of  sight  of  one  eye.  The  visual  disturbance  is  most  common 
with  hemiantesthesia.  It  is  more  marked  on  the  affected  side, 
but  exists  to  some  extent  on  the  healthy  side.  The  limitation  of 
the  fields  is  shown  in  the  accompanying  cut  (Fig.  193). 

Hearing.  There  is  sometimes  a  diminution  in  the  acuity  of 
hearing  of  one  ear,  and  this  occurs,  if  present,  in  connection  with 
hemiansesthesia.  There  may  also  be  a  loss  of  hearing  to  high 
and  low  notes,  while  hearing  is  apparently  fairly  good  to  notes  of 
medium  range ;  and  finally  there  may  be  a  diminution  in  hearing 
by  bone  conduction,  while  hearing  by  aerial  conduction  is  but 


Fig.  193.— Hysterical  Loss  of  Color  Sense  and  Limitation  op  Visual  Field. 
Color  sense  absent  in  left  eye  and  field  contracted;  in  right  e5e  field  less  con- 
tracted ;  order  of  appreciation  of  colors  from  without  in  was  yellow,  violet,  blue, 
red,  green  (observation  by  Dr.  E.  S.  Peck). 

little  impaired,  this  being  due  probably  to  an  anaesthesia  of  the 
acoustic  nerve. 

Disturbances  of  taste  in  the  form  of  anaesthesia  or  paraesthesia 
are  quite  frequent  and  are  important  signs  in  hysteria.  The 
loss  of  the  sense  of  taste  may  only  involve  the  back  portion  of 
the  tongue  and  the  palate ;  in  other  words,  the  taste  field  is  here 
limited  as  it  is  with  hearing  and  vision. 

The  sense  of  smell  may  be  abolished,  but  this  usually  occurs 
in  connection  with  hemianaesthesia. 

Hyperaesthesias  and  neuralgias.  Pure  neuralgias  are  some- 
what rare  in  true  hysteria,  but  hyperaesthesia  and  pains  of  vari- 
ous kinds  are  not  at  all  infrequent.  Hyperaesthesia  occurs  in  the 
form  of  patches  at  different  parts  of  the  body.  These  sensitive 
points  may,  when  pressed  upon,  bring  on  paroxysms  of  various 


422  DISEASES  OF  THE  NERVOUS   SYSTEM. 

kinds,  and  they  are  therefore  called  the  hysterogenic  zones  (Fig. 
192).  The  most  common  seat  of  these  zones  in  women  is  over  tlie 
ovaries ;  in  men,  in  regions  correspondng  to  the  ovaries  and  on  the 
scrotum.  Hysterogenic  zones,  however,  may  be  found  just  be- 
neath the  mammary  gland,  on  the  epigastrium,  along  the  spine, 
and  in  other  places.  These  zones  are  sensitive  areas ;  they  can  be 
made  to  disappear  by  applications  of  electricity  and  by  refriger- 
ation and  counter-irritation.  Hysterical  patients  often  sufTer 
from  local  headaches  which  are  apt  to  be  confined  to  the  top  of 
the  head  or  to  the  sides  near  the  temples.  The  pain  is  severe, 
sharp,  and  boring,  and  may  exacerbate  with  such  intensity  as  to 
jiroduce  symptoms  almost  resembling  meningitis.  The  spot-like 
pains  are  known  as  hysterical  clavus.  Hysterical  jjatients  occa- 
sionally have  migraine,  facial  neuralgia,  i  nd  intercostal  neural- 
gia. Much  more  often  they  have  pains  along  the  spine,  produc- 
ing symptoms  of  spinal  irritation.  Hysterical  patients  also  have 
at  times  attacks  of  palpitation  and  pains  over  the  heart,  consti- 
tuting what  is  known  as  pseudo-angina.  Such  troubles  are  much 
more  frequent  in  women. 

Motor  symptoms.  The  motor  symxDtoms  of  hysteria  are  paral- 
yses, amyosthenia,  contractures,  tremor,  and  choreic  and  ataxic 
movements.  The  i^aralyses  of  hysteria  take  the  form  of  hemi- 
plegia, paraplegia,  and  monoplegias.  Hysterical  hemiplegia  oc- 
curs usually  rather  suddenly,  often  as  the  result  of  some  severe 
shock.  The  left  side  is  more  frequently  attacked.  The  arm  is 
most  affected,  the  leg  next,  while  the  face  is  hardly  ever  in- 
volved. The  paralysis  is  not  an  absolute  one,  and  the  patient  is 
able  to  drag  himself  along.  The  deep  reflexes  are  usuallj'  not 
exaggerated  and  they  may  be  for  a  short  time  absent.  The  paral- 
ysis is  thus  a  flaccid  one.  The  gait  of  the  patient  is  different  from 
that  of  hemiplegia  due  to  organic  disease ;  in  hysterical  hemi- 
plegia the  patient  drags  the  paralyzed  leg  after  him,  in  organic 
hemiplegia  the  ijatient  swings  the  paralyzed  leg  around  in  a  half 
circle.  This  peculiarity  of  the  gait,  the  absence  of  exaggerated 
reflexes,  the  absence  of  paralysis  of  the  face,  and  the  presence 
very  commonly  of  other  hysterical  stigmata  are  sufficient  to  en- 
able one  to  make  the  diagnosis.  Sometimes  the  face  on  the 
affected  side  is  slightly  drawn  by  a  spasm  so  that  it  appears  to  be 
paralyzed,  when  it  really  is  not  (Charcot).  Monoplegias  affect 
the  arm  or  leg,  very  rarely  indeed  the  face,  occasionally  the  eye 
muscles,  and  most  commonly  of  all  the  muscles  of  the  larynx. 
Hysterical  monoplegia  is  usually 'accompanied  with  anaesthesia 
of  the  affected  part  and  by  other  symptoms  of  hysteria.  There 
are  no  serious  atrophic  changes  or  disturbances  of  the  electrical 
reactions.  Hysterical  eye  palsies  show  themselves  in  the  form 
of  tenest  of  an  insufficiency  of  the  internal  recti,  much  more  rarely 


HYSTERIA.  423 

by  a  paralysis  of  the  third  nerve  or  some  of  its  branches.  In 
hysterical  palsy  of  the  larynx  the  adductors  are  involved  so 
that  the  patient  cannot  speak  aloud,  and  the  condition  is  called 
hysterical  aphonia.  The  trouble  often  comes  on  suddenly,  the 
patient  finding  that  he  cannot  speak  above  a  whisper.  The 
paralysis  is  not  so  great  but  that  the  adductors  can  be  approxi- 
mated in  coughing.  The  trouble  is  distinguished  from  laryngeal 
inflammation  by  inspection  of  the  affected  part.  The  abductors 
of  the  larynx  and  the  tongue  and  other  muscles  of  articulation 
are  in  very  rare  cases  also  involved,  and  hysteria  may  produce 
symptoms  resembhng  a  bulbar  paralysis.  Paraplegia  is  a  rather 
common  form  of  hysterical  palsy;  it  is  usually  brought  on  by 
emotions  of  depressing  character,  often  associated  with  some 
slight  injury.    It  may  be  accompanied  with  a  good  deal  of  pain 


Fig.  194.— Hysterical  Contractures. 

in  the  back,  and  the  form  of  disease  which  is  popularly  known  as 
"  spinal  concussion "  consists  in  many  cases  of  hysterical  para- 
plegia combined  with  hysterical  neuralgia  of  the  spine.  In 
hysterical  paraplegia  there  is  very  little  wasting  of  the  limbs 
and  no  change  in  the  electrical  reactions.  The  deep  reflexes  may 
be  somewhat  increased  or  normal;  they  are  never  absent. 
There  is  never  any  prolonged  or  persistent  ankle  clonus,  but  there 
may  be  a  short  or  spurious  clonus  due  to  a  general  exaggerated 
irritability  of  the  nervous  system.  The  sphincters  are  never  in- 
volved except  temporarily  or  through  some  complication. 

Amyosthenia  is  a  frequent,  peculiar,  and  interesting  symptom 
occurring  in  the  interparoxysmal  stage  of  hysteria.  It  consists 
in  a  more  or  less  temporary  feeling  of  weakness  of  an  arm  or  of 
the  legs.  Thus  a  person  in  lifting  a  dish  from  the  table  suddenly 
feels  the  arm  give  out,  and  if  not  careful  the  dish  is  dropped;  or 
while  walking  the  patients  suddenly  feel  as  though  they  had  lost 
all  power  in  the  lower  limbs.  This  amyosthenic  condition  is 
generally  temporary,  but  it  may  be  so  permanent  as  to  produce  a 


424  DISEASES  OF  THE  NERVOUS  SYSTEM. 

certain  degree  of  monoplegia  or  paraplegia.  The  amyosthenic 
condition  generally  precedes  a  paralysis.  It  presents  no  objec- 
tive signs  in  the  way  of  electrical  reaction ;  it  involves  a  whole 
member,  not  a  single  group  of  muscles ;  it  affects  more  the  anaes- 
thetic side,  and  when  it  exists  the  deep  reflexes  are  usually  exag- 
gerated (Toui-ette). 

Contractures.  In  some  forms  of  hysteria  there  is  a  tendency 
for  the  muscles  to  undergo  contracture  under  slight  mechanical 
stimulation  such  as  pressure  or  a  blow.  This  tendency  to  con- 
tracture in  hysteria  is  called  the  contractural  diathesis,  and  it  is 
an  important  sign.  The  contractures  may  be  temporary,  disap- 
pearing soon  after  the  exciting  cause  ceases,  or  they  may  develop 
independently  and  last  for  a  long  time.     They  involve  the  legs, 


Repose.  Movement. 

Fig.  195.— Illustrating  Intentional  Tremor  in  Hysteria  (Tourette). 

arms,  and  facial  muscles,  and  may  be  associated  with  paralysis 
and  anaesthesia. 

Tremor  occurs  in  hysteria  in  a  considerable  proportion  of 
cases,  more  especially  those  in  which  there  is  hemiplegia  and  hemi- 
antesthesia.  Hysterical  tremor  simulates  all  the  various  types. 
The  common  form  is  one  in  which  the  oscillations  occur  from 
five  and  a  half  to  seven  and  a  half  times  a  second,  and  it  is  there- 
fore a  tremor  of  average  rhythm.  It  ceases  for  a  time  when  the 
person  is  quiet  or  lies  in  the  horizontal  position;  also  during 
sleep.  It  affects  the  head  and  tongue  as  well  as  the  extremities, 
the  latter  more  upon  one  side  than  the  other.  It  may  be  chiefly 
in  the  lower  limbs.  Sometimes  it  has  the  type  of  an  intentional 
tremor,  ceasing  on  rest  of  the  hand  and  increasing  when  the  hand 
is  moved,  as  in  raising  a  glass  to  the  lips  (Fig.  195).  It  then  resem- 
bles exactly  the  tremor  of  multiple  sclerosis.  There  may  be  a  slow 
tremor  of  four  to  five  and  a  half  oscillations  per  second ;  this  per- 
sists during  rest  and  is  but  little  modified  by  voluntary  move- 
ments. It  imitates  the  tremor  of  paralysis  agitans.  Finally 
there  may  be  a  rapid  tremor  of  eight  to  nine  oscillations  per 
second.     This  also  persists  during  repose  and  is  but  little  modi- 


HYSTERIA.  425 

fled  by  movements.  It  imitates  the  tremor  of  Basedow's  disease, 
alcoholism,  and  neurasthenia. 

The  mental  state  in  hysteria  is  characterized  by  emotional  in- 
stabihty  and  intense  craving  for  sympathy,  weakness  of  the  will, 
lack  of  self-control,  acuteness  of  perception,  and  a  constant  vari- 
ability of  moods.  The  hysterical  mind  is  not  a  dull  one,  it  is  not 
a  consciously  mendacious  or  evil  one.  But  there  is  an  abnormal 
increase  of  sensibility  and  an  exaggeration  of  the  personal  feel- 
ing or  egotism  which  leads  to  selfishness  and  promjjts  deceit. 

The  fundamental  defect  in  the  hysterical  brain  is  that  it  is 
circumscribed  in  its  associative  functions;  the  field  of  conscious- 
ness is  limited  just  as  is  the  field  of  vision.  The  mental  activity 
is  confined  to  personal  feelings,  which  are  not  regulated  by  con- 
notation of  past  experiences,  hence  they  flow  over  too  easily  into 
emotional  outbursts  or  motor  paroxysms.  The  hysterical  person 
cannot  think. 

Physiologically  the  condition  is  explained  by  supposing  that 
there  is  a  benumbing  of  the  association  fibres  which  normally 
connect  sensory  cortical  centres  with  other  parts  and  enable  one 
to  compare  and  adjust  new  experiences  with  old.  In  other  words, 
to  reason  and  form  correct  judgments. 

Underlying  the  hysterical  mental  state  there  is  a  condition  of 
suggestibility^  by  reason  of  which  ideas  and  impressions  easily  be- 
come fixed  and  dominate  the  mind.  The  person  becomes  self- 
hypnotized  and  believes  he  or  she  is  suffering  from  things  which 
have  no  objective  existence.  The  pains,  palsies,  and  anaesthesias 
of  hysteria  major  are  pseudo-delusions,  differing  from  delusions 
of  the  insane  in  that  the  false  belief  or  idea  is  a  subconscious  one. 

Trophic  disorders.  In  hysterical  paralysis  a  slight  amount  of 
atrophy  occurs,  but  only  such  as  would  naturally  follow  disuse 
of  the  part.  A  very  few  cases  have  been  reported  in  which  a 
true  neurotic  atrophy  resembling  the  atrophy  that  occurs  in  neu- 
ritis or  progressive  muscular  atrophy  was  present,  and  it  is  even 
affirmed  that  degenerative  reactions  may  be  elicited.  Cutaneous 
eruptions  and  dystrophies  practically  do  not  exist,  or,  if  present, 
are  the  result  of  complicating  disorders. 

Visceral  symptoms.  Hysterical  patients  often  suffer  from 
dyspepsia  and  constipation,  also  from  anorexia  and  in  some  cases 
from  persistent  vomiting  or  regurgitation  of  food.  Occasionally 
the  anorexia  and  vomiting  become  persistent;  the  patient  refuses 
food  or  rejects  all  that  is  taken;  she  emaciates,  becomes  weak 
and  bed -ridden,  and  develops  into  that  particular  phase  of  hys- 
teria known  as  "  the  fasting  girl."  In  these  cases,  along  with  the 
aversion  to  food  and  vomiting,  there  may  be  a  great  deal  of  gas- 
tralgia.  The  urine  in  hysteria  is  apt  to  be  of  low  specific  gravity. 
Always  after  hysterical  attacks  there  is  a  profuse  flow  of  very 


426  DISEASES   OF  THE  NERVOUS  SYSTEM 

light-colored  urine  having  a  gravity  of  only  1,003  to  1,006.  Some- 
times there  is  retention  of  urine ;  in  extremely  rare  cases  there  is 
a  condition  known  as  ischuria  and  anuria,  in  which  for  several 
days  extremely  small  quantities  of  urine  are  passed,  owing  ap- 
parently to  a  suspension  of  the  functions  of  the  kidney.  Such 
cases  should  always  be  carefully  investigated,  to  see  that  the 
patient  does  not  deceive  her  attendants  in  regard  to  the  amount 
of  urine  passed. 

Vasomotor  symptoms  are  very  common.  They  consist  of 
flushings  and  pallor,  cold  extremities,  an  1  at  times  an  (Edematous 
condition  of  one  or  more  extremities.  This  oedema  may  be  of 
the  ordinary  pale,  waxy  character,  pitting  upon  pressure.  In 
other  cases  it  has  a  i^eculiar  bluish  tinge  and  it  does  not  pit; 
the  hands,  which  are  the  parts  generally  affected,  are  several 
degrees  below  the  normal  in  temperature,  and  the  limb  resembles 
in  some  respects  the  condition  in  Reynaud's  disease.  Gangrene, 
however,  never  supervenes.  This  form  of  oedema  is  known  as 
the  blue  cedema  of  hysteria. 

There  occur  in  hysteria  febrile  attacks,  and  much  has  been 
written  upon  the  subject  of  hysterical  femr.  These  so-called 
hysterical  pyrexias  may  resemble  in  their  course  typhoid  or 
malarial  fever ;  as  a  rule,  the  temperature  runs  a  very  irregular 
course,  and  the  fever  often  lasts  for  weeks  or  even  months.  The 
essentially  neurotic  origin  of  these  fevers  has  hardly  yet  been 
established,  and  one  can  only  reach  the  diagnosis  by  most  care- 
fully excluding  all  other  possible  causes. 

Anaemia  is  a  very  common  condition  in  hysterical  patients. 

Hystero-Epilepsy. — The  form  of  hysteria  which  shows  itself  by 
the  development  of  severe  crises  known  as  hystero-epileptic  at- 
tacks is  extremely  rare  in  this  country,  at  least  in  its  typical 
phase.  It  has  been  particularly  studied  by  the  French  waiters 
Charcot,  Richer,  and  others.  Hystero-epilepsy,  as  this  form  of 
the  disease  is  called,  is  a  true  hysteria  and  not  epilepsy  at  all, 
nor  a  mixture  of  hysteria  and  epilepsy,  though  the  name  would 
suggest  that  that  was  the  case.  The  typical  attacks  of  hystero- 
epilepsy  begin  with  certain  prodromata  consisting  of  a  feeling  of 
malaise  and  irritability  which  may  last  for  several  hours  or  a 
day.  The  attack  is  ushered  in  often  with  an  aura,  the  patient 
utters  a  cry,  falls  to  the  ground,  loses  consciousness,  and  enters 
into  the  first  phase,  known  as  the  epileptoid  stage.  During  this 
she  suffers  from  tonic  and  clonic  spasms  very  much  like  those  of 
true  epilepsy.  The  muscles  finally  relax,  and  the  patient  be- 
comes comatose  for  a  moment  and  then  enters  the  second  stage, 
that  of  the  contortions  and  grand  movements.  In  this  there  is 
opisthotonos,  the  body  is  arched  up,  and  there  are  violent  move- 
ments of  the  trunk  and  limbs,  which  undergo  flexion  and  exten- 


HYSTERIA. 


427 


sion,  the  movements  being  all  of  large  range.  The  next  stage  is 
that  of  emotional  attitudes,  during  which  the  patient  seems  to  be 
experiencing  intense  feelings  of  anger,  joy,  or  some  other  violent 
passion,  which  she  expresses  by  the  postures  of  her  body,  the 
movements  of  the  eyes  and  facial  muscles.  This  stage  over,  she 
enters  into  the  last  phase,  which  is  known  as  that  of  delirium, 
during  which  there  is  a  great  deal  of  mental  excitement  of  a 


1  Epileptcid 


^Mmym^ymrnxmrnm^^    yimmn.nmnu^.mwmminmv 


uniiiulinini'iii' 


Z  Grand  Movements 


.._   yf'^^ 


3  Passional 


•"i(lU(lil(l'l(l(|((i/i|ii|||l(,  , 

4  JJelinctis 


Fig.  196.— Showing  the  Different  Stages  of  a  Hystero-Epileptic  Seizure 
(after  Richer). 

depressing  character,  from  which  she  gradually  emerges  into  her 
normal  condition.  To  recapitulate :  we  have  in  a  typical  attack, 
first,  prodromata ;  second,  the  epileptoid  phase,  lasting  from  one 
to  three  minutes;  third,  the  phase  of  contortions  and' grand 
movements,  one  to  three  minutes;  fourth,  the  emotional  phase, 
lasting  from  five  to  fifteen  minutes;  and,  finally,  the  stage  of 
delirium,  lasting  a  variable  time ;  the  whole  attack  lasting  from 
five  to  twenty  minutes  (Fig.  196).  In  this  country  we  occasion- 
ally see  hysterical  patients  exhibiting  one  or  two  of  these  phases, 


428  DISEASES  OF  THE  NERVOUS  SYSTEM. 

but  very  rarely  indeed  do  they  ever  go  through  the  whole  series. 
The  patients  who  suffer  from  hystero-epileptic  attacks  generally 
during  the  interparoxysmal  stage  present  many  of  the  stigmata 
of  hysteria  such  as  paralyses,  contractures,  and  anaesthesias. 

Hysterical  crises  which  take  the  form  of  convulsions  or  emo- 
tional seizures  sometimes  end  or  are  associated  with  attacks  of 
catalepsy  or  trance  or  attacks  of  amnesia  and  cerebral  automa- 
tism. As  these  conditions  all  occur  in  other  diseases  than  hys- 
teria, they  will  be  described  elsewhere  in  connection  with  the 
subject  of  the  disorders  of  sleep  and  of  consciousness. 

Hysterical  persons  occasionally  are  attacked  with  violent  and 
IDersistent  hiccoughing  or  sneezing.  Sometimes  also  there  come 
on  attacks  of  extremely  rapid  breathing  or  hysterical  polypnoea, 
during  which  the  respirations  run  up  to  fifty  or  seventy  a  minute. 
A  hysterical  cough  sometimes  occurs;  it  lasts  for  a  long  time. 
CEsoi^hageal  spasm  with  consequent  dysphagia  is  another  one  of 
the  somewhat  rare  phenomena  of  hysteria. 

Pathology. — There  is  no  known  anatomical  change  at  the  basis 
of  hysteria.  We  do  not  find  the  marks  of  degeneration  as  we  do 
in  certain  forms  of  insanity  and  epilepsy.  The  pathology  of 
hysteria  is  really  its  psychology.  It  is  a  brain  disease  affecting 
primarily  the  cortex,  while  secondarily  lower  centres  are  involved. 
The  essential  trouble  is  on  the  one  hand  a  benumbing  of  the 
associative  and  inhibitory  tracts  of  the  brain  so  that  the  sensa- 
tions are  dammed  up  till  they  promiscuously  overflow.  On  the 
other  hand,  the  receptive  areas  are  over  irritable  and  sensitive. 
The  field  of  consciousness  is  narrowed  but  exalted  in  intensity. 

Diagnosis. — Physicians  recognize  three  different  phases  of 
hysteria — a  hysterical  temperament,  hysteria  minor,  and  hysteria 
major.  The  hysterical  temi3erament  is  something  with  which 
all  women  and  many  men  are  naturally  endowed.  It  is  a  condi- 
tion, not  a  disease,  and  does  not  call  for  description  or  elucida- 
tion here.  Hysteria  minor  is  the  hysterical  temperament  plus 
certain  stigmata  and  the  crises.  One  should  not  make  the  diag- 
nosis of  hysteria  minor  unless  he  can  find  these  factors.  The 
stigmata  we  have  already  enumerated,  also  the  peculiar  and 
varied  forms  in  which  the  crises  show  themselves.  In  hysteria 
major  we  have  a  much  greater  iDreponderance  of  the  stigmata 
and  much  severer  forms  of  the  crises,  these  being  largely  of  a 
motor  type.  Hysteria  simulates  many  organic  diseases,  and  it  is 
often  'difficult  to  distinguish  surety  the  real  from  the  spurious 
thing.  The  essential  characteristics  of  hysterical  forms  of  dis- 
ease are  the  peculiar  emotional  condition  of  the  patient,  the  past 
history  of  hysterical  crises,  the  presence  of  the  stigmata  of  hys- 
teria such  as  anaesthesias,  limitation  of  the  visual  field,  paralyses, 
and  contractures.     The  variability  of  the  symptoms,  their  sus- 


HYSTERIA.  429 

ceptibility  to  influence  under  suggestion  and  rigorous  moral 
measures,  the  absence  of  serious  disturbance  of  nutrition,  the  sex 
and  age,  and  tlie  cause  should  also  have  weight  in  guiding  us  to 
our  decision. 

Diagnosis  of  special  forms  of  hysterical  manifestations.  Hys- 
terical paralysis  is  characterized  by  the  fact  that  there  is  no 
marked  degree  of  wasting  of  the  muscles,  no  electrical  reactions 
of  degeneration,  the  deep  reflexes  are  preserved  or  exaggerated, 
and  other  marks  of  hysteria  are  present.  Hysterical  anaesthesia 
can  generally  be  lessened  over  certain  areas  by  the  application  of 
the  magnet  or  ca,n  be  made  temporarily  to  disappear;  it  is  pecul- 
iarly distributed  in  the  way  described  under  symptoms  and  is 
associated  with  aneesthesias  of  the  special  senses.  Hysterical 
contractures  sometimes  cease  during  sleep  and  always  under  deep 
narcosis,  and  the  use  of  an  anaesthetic  may  clear  up  the  case. 
They  usually  follow  a  fit,  an  injury,  or  an  oi^eration.  They  are 
somewhat  increased  on  attempts  to  overcome  them  by  force ;  they 
are  usually  associated  Avith  paralysis  and  anaesthesia  and  other 
hysterical  symptoms. 

Hysterical  convulsions.  These  differ  from  convulsions  of  epi- 
lepsy in  the  way  best  indicated  by  the  following  table  ■ 

Hysterical  Convulsion.  Epileptic  Convulsion. 

Brought  on  by  emotion  or  injury;  no  The  opposite  in  all  these  particulars, 
aura  ;  no  initial  cry  ;  movements  co- 
ordinate ;  tongue  not  bitten,  and  pa- 
tient never  injures  herself.  Duration 
perhaps  several  hours  with  intermis- 
sions ;  consciousness  generally  pre- 
served. Micturition  and  defecation  do 
not  occur.  No  rise  of  temperature; 
may  be  stopped  artificially. 

The  hystero-epileptic  attacks  are  so  characteristic  that  a  mis- 
take could  not  be  made. 

Prognosis.— The  prognosis  of  hysteria  in  children  is  good. 
They  generally  get  well,  although  in  some  cases  there  is  a  recur- 
rence later  in  life.  In  liysteria  minor  of  young  adults  the  prog- 
nosis varies  with  the  severity  of  the  disease  and  with  the  physi- 
cal strength,  mental  endowment,  and  social  environment  of  the 
patient.  Mild  forms  of  hysteria  under  proper  treatment  usually 
get  well.  The  severer  forms  are  often  intractable  even  under  the 
best  treatment.  When  a  severe  form  of  hysteria  occurs  in  a 
person  of  feeble  frame  who  is  surrounded  with  a  sympathetic 
family,  the  task  of  rescuing  her  from  her  disorder  is  a  very  ardu- 
ous one.  Traumatic  forms  of  hysteria  which  are  not  infrequently 
associated  with  some  actual  physical  injury  are  often  difficult 
to  cure.     Hysteria  which  is  associated  with  some  organic  disease, 


430  DISEASES  OF  THE  NERVOUS  SYSTEM. 

such  as  a  severe  pelvic  disorder  or  an  organic  affection  of  the 
central  nervous  system,  has  a  bad  prognosis.  Hysteria  in  the 
male  is  generally  curable,  but  it  requires  vigorous  treatment,  and 
spontaneous  cure  is  by  no  means  likely  to  happen. 

Treatment.— The  treatment  of  hysteria  may  be  divided  into 
the  mental,  mechanical,  dietetic,  and  medicinal. 

By  all  odds  the  most  imi^ortant  factor  in  the  treatment  of 
hysteria  is  the  mental  treatment,  and  the  most  imiDortant  meas- 
ure to  be  taken  is  the  isolation  of  the  patient.  She  should  be 
placed  where  she  will  not  be  surrounded  by  sympathetic  friends ; 
where  her  life  will  be  a  regular  one ;  where  some  occupation  may 
be  given  which  will  engross  her  attention,  interest  her  mind,  and 
call  into  play  her  physical  activities.  In  the  major  forms  of 
hysteria  associated  with  anorexia,  emaciation,  anaemia,  and  pos- 
sibly pelvic  disorders,  the  "rest  cure"  as  elaborated  and  carried 
out  by  Weir  Mitchell  forms  by  all  odds  the  most  successful  means 
of  treatment.  In  many  cases  of  less  severe  character  a  partial 
rest  cure  in  which  the  patient  is  separated  from  her  family  but  is 
not  placed  under  such  severe  restrictions  may  be  all  that  is 
needed.  In  the  case  of  children  removal  from  home  is  often 
advisable,  and  the  discipline  of  well-conducted  schools  is  a  most 
excellent  measure. 

The  mechanical  means  used  in  hysteria  are  hydrotherapy, 
electricity,  massage,  and  exercise.  Of  these  measures  hydro- 
therapy and  electricity  take  the  first  rank.  In  hydrotherapy  the 
douche  or  jet  to  the  back,  the  shower  and  cold  plunge,  and  the 
half  bath  are  the  most  efficacious.  The  technique  of  their  use  is 
given  elsewhere.  In  the  electrical  treatment  the  static  and  fara- 
dic  currents  give  the  best  results.  The  static  sparks  often  relieve 
contractures  and  lessen  or  I'emove  the  anaesthesias,  and  both 
forms  of  electricity  seem  to  have  a  generally  beneffcial  tonic  ef- 
fect. Massage  is  of  some  value  in  promoting  nutrition,  and  it  also 
has  a  favorable  sedative  effect  on  many  cases.  Exercise,  particu- 
larly of  an  active  kind  such  as  stimulates  the  mind  and  interests 
one,  is  a  measure  of  extreme  value  and  one  which  has  perhaps 
not  been  sufficiently  api^reciated.  The  use  of  the  bicycle,  play- 
ing tennis,  and  horseback-riding  are  measures  which  cannot  be 
too  strongly  recommended  to  hysterical  women;  in  fact,  it  is 
probable  that  some  cases  which  are  submitted  to  the  rest-cure 
treatment  might  do  better  by  an  entirely  opposite  kind  of  pro- 
cedure. 

The  drugs  Avhich  can  be  recommended  in  hysteria  are  not 
numerous  and  their  power  is  limited.  Valerianate  of  zinc,  tur- 
pentine, asafoetida,  tincture  of  sumbul,  iron,  and  the  bromides 
are  the  most  important  of  the  nervines.  In  hysterical  children 
a  capsule  containing  two  grains  of  valerianate  of  zinc  and  one  of 


THE  SPASMODIC  TICS.  431 

sulphate  of  quinine  is  often  efficacious.  Gowers  places  more  reli- 
ance upon  the  oil  of  turpentine  in  doses  which  should  be  increased 
to  the  point  of  strangury.  Pitres  recommends  the  wearing  of 
colored  glasses  in  order  to  keep  off  hysterical  attacks.  Some  ex- 
perimentation is  necessary  in  order  to  see  which  color  is  most 
suited  to  the  case. 

In  the  treatment  of  hysterical  convulsions  the  most  efficient 
measure  is  the  administration  of  an  emetic,  and  this  can  be  best 
done  by  giving  hypodermically  one- twelfth  of  a  grain  of  apomor- 
phine.  Convulsions  can  be  stopped  sometimes  by  throwing  water 
in  the  face  or  on  the  epigastrium ;  by  firm  and  somewhat  long- 
continued  pressure  over  the  ovaries;  by  the  administration  of 
valerian,  aromatic  spirits  of  ammonia,  or  compound  spirits  of 
ether. 

The  Spasmodic  Tics  (Tic  Cona^ulsif). 

Spasmodic  tic  is  a  disease  to  which  the  name  of  chorea  is 
often,  but  incorrectly,  given.  It  is  a  very  chronic  disorder,  and 
shows  itself  in  the  form  of  quick,  electric-like  spasms  of  certain 
groups  of  muscles  or  single  muscles.  The  s^Dasmodic  move- 
ments are  violent,  and  several  rapid  contractions  succeed  each 
other,  after  which  there  is  a  period  of  rest.  The  spasm  has  a 
tendency  to  become  localized  in  certain  nerves,  especially  the 
facial  {mimic  tic),  or  even  in  a  single  branch  or  twig,  as  that  to 
the  orbicularis,  the  zygomaticus,  the  diaphragm,  or  the  tensor 
tympani.  Spasmodic  tic  sometimes  involves  the  muscles  of  ex- 
piration and  the  larynx,  and  then  it  has  been  wrongly  called 
chorea  of  the  larynx.     Stuttering  is  a  form  of  tic. 

The  convulsive  movements  may  take  a  wide  range  and  affect 
a  number  of  groups  of  muscles,  producing  quick,  violent  move- 
ments of  the  body.  They  are  sometimes  accompanied  with  ex- 
plosive disturbances  of  speech.  In  these  cases  the  patient  at  the 
time  of  the  convulsive  movement  utters  some  obscene  or  profane 
words  {coprolalia),  or  involuntarily  repeats  the  last  words  of  the 
sentence  spoken  to  him  {echolalia),  or  spasmodically  imitates  a 
gesture  made  to  him  {echokinesis),  or  involuntarily  exclaims  the 
thought  uppermost  in  his  mind,  perhaps  revealing  some  secret 
against  his  will  {tic  cle  pensee). 

The  peculiar  disorder  of  the  Maine  "jumpers,"  characterized 
by  sudden  violent  movements  on  being  touched  or  startled,  is  a 
form  of  tic.  So  also  are  the  similar  troubles  known  as  Za/a/?, 
occurring  in  Malay,  and  imjriachit,  occurring  in  Siberia  and 
Kamchatka. 

Most  of  the  special  forms  of  spasmodic  tic  (mimic  tic,  wry- 
neck, etc.)  have  been  described  elsewhere, 

ISpasmodic  tic  with  coprolalia  affects  children  between  the 


432  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ages  of  six  and  sixteen  years,  and  by  preference  the  masculine 
sex.  There  is  almost  always  a  neurotic  family  history,  and  the 
children  are  nervous. 

The  disease  begins  with  attacks  of  violent  and  irregular  move- 
ments, affecting  generally  the  head,  face,  and  upper  extremities 
first,  then  involving  the  whole  body.  The  movements  can  be  con- 
trolled for  a  time  by  the  will,  only  to  break  out  with  increased 
violence  later.  They  cease  entirely  during  sleep,  which  is  gen- 
erally profound. 

After  having  suffered  from  the  disease  for  a  time,  the  patient 
will,  with  the  attacks,  utter  inarticulate  cries,  or  he  may  begin 
to  repeat  or  echo  the  words  that  he  overhears.  All  this  is  done 
automatically  and  suddenly,  Avith  the  accompaniment  of  grimaces 
and  muscular  contortions.  The  special  peculiarity  of  the  disease 
is  the  sudden  interjection  by  the  patient  of  obscene  words  and 
expressions  (coprolalia). 

The  disorder  is  chronic,  lasting  for  years.  It  is  best  treated 
by  isolation,  tonics,  and  ordinary  antispasmodics. 

Paramyocloxus  MuiiTiPiiEX  (Myoclonus  Multiplex, 
CoxvuLsiYE  Tremor,   Myospasia). 

Myoclonus  multiplex  is  a  rare  disease  allied  in  nature  to  the 
convulsive  tics  and  characterized  by  attacks  of  quick  clonic 
spasms  affecting  the  trunk  and  sometimes  the  extremities  also. 
The  disease  occurs  most  often  in  adult  males.  It  is  caused  usually 
by  fright,  injury,  or  some  violent  emotion.  Very  different  forms 
of  spasm  have  been  described  under  the  name  myoclonus  multi- 
plex, but  in  the  typical  disease  the  patient  without  warning  is 
seized  with  sudden  and  lightning-like  contractions  of  the  trunk 
and  hip  muscles,  which  cause  his  body  to  be  alternately  flexed  and 
extended  so  violently  that  he  is  often  thrown  from  the  chair  or 
couch  on  which  he  is  lying.  The  arms  and  legs  may  be  also  in- 
volved, and  the  attack  takes  on  the  characteristics  of  a  general 
tremor  in  Avhich  the  Avhole  body  shakes.  The  facial  muscles  may 
be  affected.  The  spasmodic  movements  are  bilateral,  although 
they  sometimes  begin  on  one  side.  The  convulsions  differ  from 
those  of  hysteria  in  that  they  affect  groups  of  muscles  that 
have  not  the  same  physiological  function  and  produce  move- 
ments which  cannot  be  easily  imitated  voluntarily.  Still  this 
distinction  is  not  a  sharp  one.  The  patients  are  generally  neu- 
rasthenic or  hysterical.  They  hav-e  no  paralyses,  no  anaesthesias, 
very  few  pains,  and  their  bodily  nutrition  is  not  seriously  im- 
paired. 

The  pathology  and  pathological  anatomy  are  unknown. 

The  diagnosis  is  based  on  the  peculiar  character  of  the  spasm, 


thomsen's  disease.  433 

on  the  fact  that  the  trunk  muscles  are  involved,  and  that  the 
spasms  are  bilateral.  The  disease  usually  lasts  but  a  few  months, 
but  it  may  extend  over  a  number  of  years. 

The  prognosis  is  fairly  good. 

The  treatment  consists  of  tonics  and  the  use  of  chloral.  Gal- 
vanism seems  to  be  very  efficient.  Atropine  and  hyoscine  are 
indicated,  and  hydrotherapy  may  also  be  advantageously  em- 
ployed. 

Saltatory  Spasm. 

This  is  a  curious  and  rare  form  of  disease  characterized  by 
convulsive  movements  of  the  legs  brought  out  by  touching  the 
feet  to  the  floor.  It  occurs  in  both  sexes  and  at  all  ages,  but 
usually  in  those  of  a  neurasthenic  and  hysterical  temperament. 
The  phenomena  of  the  disease  are  exhibited  when  the  jjatient 
attempts  to  stand.  The  minute  that  the  feet  touch  the  floor  vio- 
lent contractions  occur  in  the  muscles  of  the  calves  and  hips, 
sometimes  in  the  whole  body;  these  cause  the  patient  to  jump, 
and  the  movements  may  be  so  severe  as  to  throw  him  down. 
The  seizures  are  only  brought  on  by  the  exciting  effects  of  the 
weight  of  the  body  on  the  feet.  Saltatory  spasm  is  probably  a 
form  of  hysterical  spasm.  It  has  been  described  chiefly  by  the 
older  writers,  and  its  symptomatology  and  pathology  have  not 
been  carefully  worked  out. 

Thomsen's  Disease  (Myotonia  Congenita). 

This  is  a  hereditary  family  disease  characterized  by  the  devel- 
opment of  tonic  cramps  when  the  patient  attempts  voluntary 
movements.  The  disorder  is  very  rare.  About  forty  cases  have 
been  reported,  and  in  this  country  only  three,  one  of  them  being 
a  patient  of  the  Avriter's. 

^^/oZo^?/.— Congenital  myotony  is  practically  always  heredi- 
tary and  runs  in  families.  It  affects  males  by  preference  and  de- 
velops at  the  time  of  adolescence. 

Si/mptoms.— The  patient  notices  that  on  trying  to  rise  or  walk 
his  legs  are  seized  with  a  painless  cramp,  which  in  a  few  seconds 
relaxes,  but  conies  on  again  when  the  muscular  movements  have 
been  repeated.  If  he  closes  his  hands  tightly  a  cramp  occurs 
and  he  cannot  relax  the  grip.  If  he  shuts  his  eyes  he  cannot 
open  them  for  a  moment.  The  nmscles  of  mastication  may  be 
affected,  but  the  extremities  are  the  parts  most  involved.  The 
involuntary  muscles  are  spared.  The  cramps  are  increased  by 
cold  and  nervousness;  they  are  lessened  by  nmscular  exercise. 
The  muscles  are  somewhat  hypertrophied,  and  the  patient  may 
present  the  appearance  of  a  very  strong  man.  The  actual 
strength  is  fair,  but  less  than  would  seem.  The  general  health 
may  be  good,  but  the  patients  sometimes  show  the  signs  of  low 
vitality  in  weak  digestion,  feeble  sexual  power,  and  susceptibility 

The  electrical  excitability  of  the  nerves  is  normal,  that  of  the 
28 


434  DISEASES   OF   THE   NERVOUS   SYSTEM. 

muscles  is  increased,  and  there  is  produced  a  contraction  tetanus 
by  both  currents.  In  addition  Erb  describes  a  xjeculiar  reaction 
produced  by  a  strong  stabile  galvanic  current.  It  consists  in 
the  appearance  of  wave-like  muscular  movements  passing  from 
cathode  to  anode.  This  was  not  present  in  my  case  or  Jacoby's. 
The  mechanical  excitability  of  the  muscles  is  also  increased, 

Fatholofji/.— The  disease  is  probably  a  primary  muscular  dys- 
trophy. There  may  be,  however,  a  i^eculiar  defect  in  innerva- 
tion, resulting  from  a  congenital  anomaly  of  the  motor  tracts. 
The  muscular  fibres  are  found  to  be  hypertrophied,  the  striations 
indistinct,  and  the  nuclei  increased. 

The  diagnosis  is  easily  made  by  the  characteristic  tonic 
cram])s. 

The  prognosis  is  bad  as  regards  cure,  but  the  disorder  does 
not  shorten  life. 

Treatment. — Dr.  Thomsen,  who  first  described  the  disease, 
states  that  active  muscular  exercise  benefits  patients.  No  spe- 
cific measures  are  known. 

CoxGExiTAL  Paramyotonia. 

Paramyotonia  is  the  name  given  to  a  form  of  myotonia  in 
which  the  symptoms  deviate  somewhat  from  the  typical  ones 
that  appear  in  Thomsen's  disease.  Paramyotonia  occurs  symp- 
tomatically,  congenitally,  and  in  a  peculiar  clinical  form  known 
as  ataxic.  We  have,  therefore,  symptomatic,  congenital,  and 
ataxic  forms. 

Symptomatic  paramyotonia  is  noted  most  characteristically 
in  a  certain  form  of  paralysis  agitans.  Here  the  patient,  when 
attempting  to  walk  or  to  rise  from  the  sitting  posture,  is  suddenly 
seized  with  an  apparent  rigidity  of  the  muscles  Avhicli  prevents 
him  from  stirring.  The  myotonic  condition  appears  also  in  spas- 
tic paralyses  of  spinal  and  cerebral  origin. 

Congenital  paramyotonia  is  a  family  affection  resembling  in 
this  respect  Thomsen's  disease.  The  muscular  rigidity  is  brought 
on  not  by  voluntary  movements,  but  by  exposure  to  cold  and 
often  very  slight  degrees  of  cold.  The  tonic  spasm  is  a  long  one 
and  lasts  for  from  a  quarter  of  an  hour  to  several  hours.  It 
affects  the  arms  more  than  the  legs.  The  facial  muscles  are  prone 
to  become  rigid.  The  attacks  are  followed  by  some  muscular 
weakness.  In  congenital  paramytonia  the  trouble  is  undoubt- 
edly a  primary  disturbance  of  the  muscles;  in  other  words,  a 
myopathy. 

Ataxic  paramyotonia  is  the  name  given  to  a  disorder  charac- 
terized by  transient  spasms  like  those  of  Thomsen's  disease,  as- 
sociated with  distinct  ataxia  and  also  with  weakness  and  some 
anaesthesia  (Gowers).  This  disease  is  probably  located  in  the 
spinal  cord  and  should  perhaps  be  considered  one  of  the  forms 
of  symptomatic  paramyotonia.  ISo  special  treatment  can  be 
given  for  either  of  the  two  latter  forms  of  disease,  of  which  very 
few  examples  have  been  observed.  • 

AKi2fESiA  Algera  (Paix  Palsy). 

Akinesia  algera  is  the  name  given  by  Moebius  to  a  peculiar 
form  of  paralysis  which  occurs  in  psychopathic  persons  and  is 
due  to  the  fact  that  intense  pains  are  produced  by  every  muscu- 


AKINESIA  ALGERA.  435 

lar  movement.  The  result  is  that  the  patient  hes  helplessly  in 
bed,  afraid  to  stir  hand  or  foot.  The  disease  occurs  only  in  per- 
sons who  have  a  very  unstable  nervous  system  and  generally  in 
those  who  have  a  paranoiac  tendency.  It  occurs  in  adults  only. 
Pain-paralysis  comes  on  gradually  and  affects  eventually  all  the 
muscles  of  the  extremities  and  body.  There  are  no  objective  dis- 
turbances such  as  atrophy,  electrical  degenerations,  and  anges- 
thesias.  The  muscles  and  skin,  however,  are  somewhat  tender 
to  the  touch.  The  disease  lasts  a  long  time.  The  patient  some- 
times improves,  in  other  cases  insanity  ensues.  The  disease  is 
essentially  a  form  of  insanit5%  a  pathophobia,  and  is  allied  to  the 
disorder  knoAvn  as  mysophobia.  The  paralysis  is  the  result  of 
pain  hallucination,  and  the  patient  is  afraid  to  move  the  arm  or 
leg  on  account  of  this  hallucination,  just  as  the  mysophobic 
patient  is  afraid  to  touch  anything  on  account  of  the  fear  of  con- 
tamination. 

The  prognosis  is  bad,  and  so  far  treatment  has  accomplished 
little  or  nothing. 


CHAPTER  XXIII. 
THE  ACQUIRED  NEUROSES. 

Chorea  (St.  Vitus'  Daxce). 

Under  this  name  various  spasmodic  disorders  have  been  de- 
scribed.    They  are  to  be  classed  as  follows : 

I.  Common  chorea,  or  Sydenham's  chorea. 

II.  Hereditary  chorea,  or  Huntington's  chorea. 

III.  The  convulsive  tics. 

lY.  Hysterical  chorea,  including  so-called  chorea  major. 
V.  Various  local  endemic  choreas,  such  as  the  electric  chorea 
of  Dubini  and  the  electric  chorea  of  Bergeron. 

Chorea  of  Sydenham. 

This  is  the  common  type  of  chorea,  and  is  the  disease  ordi- 
narily meant  when  the  term  chorea  is  used.  It  is  a  subacute  dis- 
order characterized  by  irregular  jerking  and  inco-ordinate  move- 
ments. The  disease  is  a  common  one,  forming  about  one-fifth  of 
the  nervous  diseases  of  children. 

Etiology. — Most  cases  occur  between  the  ages  of  five  and 
fifteen  (see  chart,  p.  405).  It  is  very  rare  under  five.  A  few  cases 
occur  after  twenty,  and  even  up  to  old  age,  when  a  senile  chorea  is 
sometimes  observed.  It  affects  girls  more  than  boys  in  the  ratio 
of  about  2.5  to  1.     In  adult  life  the  disproportion  is  less  marked. 

It  is  relatively  rare  in  the  negro  race,  especially  in  those  of 
pure  blood  (Mitchell).  In  this  country  it  is  more  common  in 
children  of  German,  Hebrew,  and  Portuguese  race. 

It  occurs  in  all  climates.  Most  cases  develop  in  the  spring 
months,  next  in  the  autumn,  next  in  winter,  and  last  in  summer. 
The  seasonal  influence  varies  in  different  localities.  In  Phila- 
delphia more  cases  occur  relatively  in  the  spring.  In  New  York 
there  is  an  almost  equal  increase  in  the  autumn.  School  attend- 
ance has  something  to  do  with  these  variations.  Choreic  attacks 
appear  to  be  related  to  increase  in  storms  (Lewis).  The  disease 
is  more  frequent  in  cities,  and  probably  in  the  poorer  classes. 
Hereditary  influence  is  slight,  bilt  it  exists.  In  a  small  percen- 
tage of  cases  one  parent  has  had  chorea,  epilepsy,  insanity,  or  a 
decided  neuropathic  constitution.  A  phthisical  or  a  gouty  his- 
tory in  parents  is  also  not  rare. 

The  chief  exciting  causes  are  injury  and  fright,  mental  worry. 


CHOREA.  43Y 

and  rheumatism.  Fright  or  some  emotional  disturbance  is  a 
cause  in  about  one-fifth  of  the  cases*.  Acute  rheumatism  is  given 
as  a  cause  in  very  varying  proportions,  ranging  from  five  to 
twenty-five  per  cent.  In  this  country  it  ranges  from  fifteen  to 
twenty  per  cent  (Sinkler,  Starr,  Sachs,  and  personal  observa- 
tions). Endocarditis  is  developed  in  the  course  of  chorea  in  a 
slightly  larger  proportion  of  cases.  This  may  exist  without  any 
manifestations  of  rheumatism.  Pregnancy  is  a  cause  of  chorea 
generally  in  primipara  and  always  in  young  women  under  twenty- 
five.  Chorea  sometimes  follows  infectious  fevers,  especially  mea- 
sles, scarlatina,  and  whooping-cough.  It  has  been  caused  in  rare 
cases  by  reflex  irritation  from  an  injury,  from  nasal  disease,  and 
sexual  disorders.  Overstudy  and  the  worry  of  examinations  are 
factors  in  causing  chorea  in  predisposed  and  badly  nourished  chil- 
dren. Intestinal  irritations,  such  as  worms,  may  excite  chorea. 
Malaria  also  may  aggravate,  if  it  does  not  produce  it.  Hamilton 
describes  a  form  of  chorea  caused  by  tobacco-poisoning.  Anaemia 
and  malnutrition  underlie  most  cases. 

Symptoms.— The  disease  may  begin  suddenly,  but  usually  it 
develops  slowly,  and  it  is  not  till  one  or  two  weeks  that  the  symp- 
toms are  decidedly  i3rominent.  It  usually  begins  with  irregular 
twitching  of  the  hand  or  face  on  one  side.  The  child  winks, 
grimaces,  and  drops  things  from  its  hand.  The  foot  and  leg  be- 
come affected  later  and  the  child  stumbles  in  walking.  In  two 
or  three  weeks  the  opposite  side  is  involved,  but  usually  less  than 
the  one  originally  affected.  In  three  or  four  weeks  the  disease 
reaches  its  height.  The  patient's  movements  are  then  almost 
continuous.  The  hands  can  hardly  be  used  and  the  child  has 
to  be  fed  and  dressed ;  even  walking  is  awkward  and  diflBcult. 
Speech  is  indistinct  and  confused  from  the  irregular  movements 
of  the  lips  and  tongue.  The  muscles  of  respiration  may  be  in- 
volved so  that  the  rhythm  is  uneven.  It  is  asserted  that  the 
heart's  action  is  affected  also ;  but  this  is  unlikely.    • 

The  choreic  movements  usually  occur  both  when  the  muscles 
are  at  rest  and  during  volitional  acts.  In  some  cases  the  disease 
is  chiefly  characterized  by  inco-ordinate  movements  when  pur- 
poseful acts  are  attempted.  In  other  cases  voluntary  movements 
can  be  readily  performed,  and  the  muscles  twitch  only  when  the 
limbs  are  at  rest.  The  movements  cease,  as  a  rule,  during  sleep. 
But  the  child  sometimes  sleeps  badly  on  account  of  the  move- 
ments. In  severe  cases  attacks  of  mental  excitement  and  even 
delirium  come  on  for  several  successive  nights,  and  this  may  be 
so  marked  a  feature  as  to  form  what  is  called  chorea  insaniens, 
or  maniacal  chorea.  Apart  from  such  phenomena,  the  mind  in 
chorea  is  usually  dulled,  the  temper  irritable,  and  the  child  much 
harder  to  manage. 


438  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  appetite  is  poor  and  capricious,  the  tongue  coated,  and 
the  bowels  often  constipated.  The  nutrition  fails  a  little ;  there 
is  anaemia  and  a  tendency  to  loss  of  flesh. 

The  eyes  present  nothing  abnormal.  Hypermetropia,  astig- 
matism, and  muscular  insufficiencies  exist,  but  not  much  more 
than  in  other  nervous  children. 

The  child  is  often  worse  in  the  morning  and  improves  toward 
night.  Excitement  and  physical  exertion  make  the  movements 
worse.  There  is  rarely  any  pain  and  never  anaesthesia  or  ten- 
derness. The  muscles  are  weak  but  not  actually  paralyzed.  The 
deep  reflexes  are  somewhat  lessened  and  the  knee  jerk  may  be 
abolished.  The  electrical  irritability  of  the  muscles  is,  as  a  rule, 
increased,  but  there  are  no  qualitative  changes.  Nocturnal  enu- 
resis occasionally  occurs.  The  urine  contains  an  excess  of  urea 
and  phosphates,  and  at  the  height  of  the  attack  the  specific 
gravity  may  be  increased. 

Forms. — Maniacal  chorea  is  characterized  by  great  mental  ex- 
citement— especially  at  night,  delirium,  with  hallucinations  and 
delusions.  AHqy  one  or  two  weeks  the  excitement  lessens  and 
the  patient  becomes  dull  and  apathetic.  Such  cases  usually  oc- 
cur in  adult  women,  and  they  are  sometimes  fatal. 

Paralytic  chorea.  In  this  form  one  arm  becomes  rather  sud- 
denly weak  and  powerless.  A  few  twitching  movements  are  ob- 
served. This  form  occurs  only  in  children  and  runs  the  same 
course  as  the  spasmodic  type. 

Chorea  of  adult  life  and  senile  chorea.  The  disease  when  it 
occurs  in  the  second  half  of  life  attacks  men  rather  oftener  than 
women ;  it  is  not  related  to  rheumatism.  There  is  usually  a  neu- 
rotic family  history  and  even  a  hereditary  history  of  chorea. 
The  attack  is  usually  caused  by  emotional  disturbances.  It  runs 
much  the  same  course  as  juvenile  chorea,  but  is  rather  more  apt 
to  become  chronic.  When  it  occurs  in  old  men  it  is  called  senile 
chorea.  This  type  is  not  to  be  confounded  with  hereditary  or 
Huntington's  chorea. 

Duration — Relapses. — The  disease  in  this  country  lasts  about 
ten  or  twelve  weeks,  ranging,  however,  from  six  weeks  to  six 
months.  There  may  be  great  improvement  followed  by  a  relapse, 
and  in  this  remittent  manner  the  disease  may  last  for  years.  If 
it  lasts  more  than  six  months  it  should  be  called  chronic.  Re- 
lapses occur  in  about  one-third  of  the  cases,  and  rather  oftener 
in  girls.  Relapses  occur  oftenest  within  a  year  of  the  first  attack 
and  much  oftener  in  the  spring.  After  three  years  relapses  prac- 
tically cease.  The  number  of  relapses  is  usually  but  one,  but  the 
disease  may  recur  eight  or  nine  times.  Relapses  rarely  occur  in 
adults  except  in  the  chorea  of  pregnancy. 

Pathology.— Th.Q  seat  of  the  lesions  in  chorea  is  the  gray  mat- 


CHOREA. 


439 


ter  of  the  cortex  and  its  meninges,  the  pyramidal  tract,  len- 
ticular nuclei,  and  the  spinal  cord.  The  lesions  are  in  acute  cases 
of  the  nature  of  intense  hyperjemia,  with  dilatation  of  vessels, 
small  hemorrhages,  and  spots  of  softening.  There  is  infiltration 
of  the  perivascular  spaces  with  round  cells  and  swelling  and  pro- 
liferation of  the  intima  of  the  small  arteries.  In  chronic  cases 
the  evidence  of  active  vascular  irritation  is  less,  but  there  are 


Fig.  197.— Perivascular  Dii^tations  in  the  White  Matter  of  the  Convolutions 
OF  A  Very  Chronic  and  Severe  Case  of  Chorea. 


perivascular  dilatations  and  increase  of  connectiv^e  tissue  (Fig. 
197).  The  process  suggests  a  low  grade  or  an  initial  stage  of  in- 
flammation. The  cause  of  this  is  probably  either  an  infective 
micro-organism  or  a  humoral  irritation  similar  to  that  causing 
the  rheumatic  symptoms  and  the  heart  lesions.  In  a  consider- 
able per  cent  of  cases  (ninety  per  cent— Osier),  especially  in  those 
of  long  duration,  there  are  fibrinous  deposits  on  the  walls  of  the 
heart.  The  hyperaemic  process  may  not  be  confined  to  the  men- 
inges and  motor  areas  of  the  brain  and  cord,  but  it  is  only  from 


4:4:0  DISEASES   OF  THE   NERVOUS   SYSTEM. 

the  disease  in  these  parts  that  the  symptoms  of  chorea  arise. 
The  presence  of  points  of  irritation  in  the  cortex  and  its  men- 
inges and  in  the  deeper  parts  excites  irregular  discharges  of  nerve 
force  and  j^roduces  the  choreic  movements.  The  interruption  of 
the  voluntary  nerve  impulses  by  diseased  foci  makes  these  move- 
ments irregular.  The  apparently  special  involvement  of  the  len- 
ticular nuclei  may  explain  some  of  the  inco-ordination.  In  para- 
lytic chorea  the  pyramidal  tract  is  probably  more  seriously 
injured  by  some  single  large  focus  of  congestion,  exudation,  or 
hemorrhage.  Indeed,  I  have  seen  a  true  hemiplegia  develop  in 
the  midst  of  an  attack.  In  maniacal  chorea  the  meninges  and 
cortex  are  more  involved. 

Diagnosis. — The  disease  is  easily  recognized  by  the  peculiar 
twitching  movements.  It  is  necessary  only  to  distinguish  the 
different  forms.  It  must  be  distinguished  from  convulsive  tic, 
electric  chorea  of  Dubini,  hysterical  spasms  which  include  myo- 
clonus, saltatory  chorea,  and  chorea  major.  The  distinctions  are 
not  difficult  and  are  given  in  connection  with  descriptions  of 
these  disorders. 

Prognosis. — As  regards  life  the  i^rognosis  is  very  favorable. 
In  this  country  death  from  chorea  hardly  ever  occurs  in  children. 
It  is  more  fatal  in  adults.  In  England  the  mortality  from  chorea 
is  about  two  per  cent.  Nearly  all  non-fatal  cases  eventually  get 
well. 

Treatment. — The  most  imjDortant  single  factor  in  treatment  is 
rest.  The  child  should  not  be  allowed  to  take  violent  exercise 
or  to  have  any  excitement.  In  most  cases  he  should  be  taken 
from  school,  and  in  bad  cases  he  should  be  kept  in  bed. 

Cold  sponging  or  the  ether  spray  daily  along  the  back  is  use- 
ful.    Nourishing  food  and  iron  are  indicated. 

As  specific  remedies,  arsenic  still  heads  the  list.  It  should  be 
given  in  doses  of  tu  v.  of  Fowler's  solution  t.  i.  d.,  increased  by  one 
or  two  drops  daily  to  fifteen  or  twenty  drops  or  even  more.  If  this 
causes  nausea  and  gastric  i^ain  or  headache,  the  dose  should  be 
stopped  for  a  day  and  then  resumed,  if  i^ossible,  where  it  was  left 
off.  Sometimes  the  suli)hide  of  arsenic  is  better  tolerated  than 
the  arsenite.  Next  to  arsenic  come  antipyrin  (gr.  v.),  antifebrin 
(gr.  iij.),  exalgin  (gr.  iij.),  the  doses  to  be  carefully  increased  if 
needed.  Tincture  of  cimicifuga  sometimes  helps  when  arsenic 
fails.  The  bromide  or  valerianate  of  zinc  is  also  an  excellent 
remedy,  especially  when  there  is  a  hysterical  element.  The  bro- 
mides and  chloral  are  useful  adjuvants  in  promoting  sleep. 
Chloral  alone  is  said  to  be  curative  if  given  in  doses  sufficient  to 
prolong  sleep  greatly  (Bastian).  Exalgin  given  cautiously  with 
iron,  in  doses  increased  to  fifteen  grains  a  day,  is  often  very  use- 
ful.    Hyoscin  hydrobromate  in  doses  of  gr.  yio  is  occasionally 


CHOREA.  441 

efficacious.  Among  other  drugs  of  less  value  are  the  salicylates, 
cypropeclium,  lobeline,  physostigmine,  and  tartar  emetic.  In 
chronic  and  obstinate  cases  hypodermic  injections  of  Fowler's 
solution  should  be  tried.  Galvanization  of  the  brain  and  spine 
is  also  useful.     Change  of  air  sometimes  breaks  up  an  attack. 

Hereditary  chorea  was  first  described  by  a  Lono-  Island 
physician,  Dr.  Waters,  in  1842,  later  by  Drs.  Gorman  and  Lyon 
and  in  1872  by  Dr.  Huntington.  The  American  cases  have  been 
observed  chiefly  in  New  York,  Connecticut,  New  Jersey  and 
Pennsylvania.  Cases  have  been  reported  also  from  Gerniany 
France,  and  England.  The  disease  rarely  begins  before  thirty 
or  after  fifty ;  it  occurs  about  equally  in  males  and  females.  It 
is  always  directly  hereditary,  either  through  father  or  mother, 
usually  the  latter.  It  begins  without  known  cause  by  twitchings 
in  the  face ;  the  movements  then  extend  to  the  arms  and  legs.  It 
is  attended  with  progressive  mental  deterioration,  with  a  ten- 
dency to  melancholia,  and  finally  ends  in  dementia.  Its  course 
is  chronic  and  usually  very  slow,  lasting  ten  or  twenty  years. 
Post  mortem,  chronic  pachymeningitis  and  leptomeningitis  with 
degenerative  changes  in  the  cortex  have  been  found. 

Electric  chorea  is  a  name  sometimes  and  wrongly  given 
to  very  violent  forms  of  ordinary  chorea  of  Sydenham.  The  term 
was  first  applied  by  Dubini  to  a  peculiar  and  progressively  fatal 
spasmodic  affection  which  has  been  observed  almost  solely  in 
Italy,  and  which  is  perhaps  of  a  podagrous  or  malignant  malarial 
origin.  M.  Bergeron  in  1880  also  described  an  "electric  chorea" 
in  which  the  patients  are  attacked  by  sudden  rhythmical  spasms. 
This  latter  disease  has  a  uniformly  favorable  course.  Neither  of 
these  diseases  resembles  true  chorea,  nor  do  they  have  the  char- 
acter of  the  tics. 

The  term  electric  chorea,  therefore,  is  one  that  should  be  only 
used,  if  at  all,  with  a  qualifying  explanation. 

Habit  Chorea  {Tic  Coordiue).— There  are  many  persons  who 
go  through  life  with  some  trick  of  speech,  of  gesture,  or  some 
peculiar  grimace.  It  may  be  only  a  shrug  of  the  shoulder,  a 
twitching  of  the  eyes,  or  a  sniff.  These  various  movements  are 
tics  of  the  co-ordinate  kind.  The  spasmodic  motion  is  of  itself 
normal,  but  is  inappropriate  and  misapplied. 

Such  movements  are  often  seen  in  children.  They  sometimes 
represent  abortive  attacks  of  chorea,  and  sometimes  they  are 
the  residuum  of  old  attacks.  In  many  cases  they  are  chronic 
convulsive  tics  from  the  start  and  have  little  relationship  to  Syden- 
ham's chorea.  The  condition  is  to  be  treated  both  by  moral  and 
medicinal  measures. 

Oscillatory  spasms  and  nodding  spasms  have  been  described 

Procursive  Chorea,  or  Dancing  Chorea— haycock^  has  de- 
scribed as  a  separate  kind  of  chorea  a  rhythmical  or  trochaic  torm, 
which  he  says  affects  children,  principally  girls,  and  shows  itseii 
in  spasmodic  rhythmical  contractions  or  in  sudden  rotating  or 


4:4:2  DISEASES   OF   THE   NERVOUS    SYSTEM. 

procursive  movements  of  the  body.  This  has  been  called  chorea 
procursive,  or  chorea  festinans,  by  other  writers.  In  many  cases 
it  is  accompanied  with  vertigo,  when  the  condition  of  the  patient 
is  similar  to  that  of  a  person  who  has  been  whirling  around  a  num- 
ber of  times.  Such  cases  always  have  decidedly  hysterical  char- 
acters, although  these  procursive  attacks  may  complicate  ordinary 
chorea. 

Chorea  major  is  a  manifestation  of  hysteria,  and  will  be  de- 
scribed under  that  subject.     It  is  not  a  chorea  at  ah. 


TETANUS. 

Tetanus  is  an  acute  or  subacute  infectious  disease  characterized 
by  violent  tonic  spasms  with  remissions  and  exacerbations.  It  is 
called  idiopathic  when  no  open  wound  is  found  and  traumatic 
when  such  condition  is  present.  When  it  attacks  infants  it  is 
called  tetanus  neonatorum;  when  the  jaws  alone  are  involved  it 
is  called  lockjaw,  or  trismus.  A  form  which  affects  the  face  and 
throat  is  called  head  or  cephalic  tetanus. 

Etiology. — It  has  a  special  predilection  for  new-born  children 
in  some  countries  (West  Indies)  and  to  a  less  extent  tor  puerperal 
women.  It  affects  males  more  than  females.  After  the  first 
month  of. life  there  is  practical  immunity  till  after  the  tenth  j'ear. 
It  then  increases  in  frequency  up  to  forty.  It  is  much  more  fre- 
quent in  dark  races  and  in  some  tropical  climates  (West  Indies, 
South  and  Central  America). 

Symptoms. — The  disease  sets  in  from  five  to  fifteen  days  after 
infection.  It  begins  with  feelings  of  stiffness  in  the  neck  and 
throat  and  sometimes  with  chilly  feelings.  Gradually  tonic 
spasms  develop  which  involve  the  trunk  muscles,  causing  opis- 
thotonos and  other  forms  of  rigid  spasm.  Trismus,  or  lockjaw, 
also  occurs.  The  spasms  are  attended  with  intense  pain.  Some- 
times there  is  a  rise  of  temperature  and  this  may  be  very  high. 
The  disease  lasts  for  two  to  five  weeks.  There  is  evidence  of  irri- 
tation and  congestion  of  the  spinal  cord  and  injured  nerves,  but 
no  special  anatomical  changes  are  found.  A  specific  bacillus 
producing  a  tetanizing  poison  has  been  discovered. 

The  diagnosis  is  based  on  the  characteristic  history  and  the 
peculiar  spasms.  In  strychnine-poisoning  there  is  no  initial  tris- 
mus or  epigastric  pain.  In  rabies  there  is  also  no  trismus  but  a 
respiratory  spasm  on  attempts  to  swallow. 

The  i^rognosis  is  bad.  About  eighty  per  cent  of  the  traumatic 
and  sixty  per  cent  of  idiopathic  ca^es  die. 

The  treatment  consists  of  complete  rest  and  quiet  in  a  dark 
room  and  the  administration  of  chloral,  bromide,  morphia,  and 
physostigma.  Successful  results  from  injection  of  blood  serum 
of  an  animal  which  has  had  the  disease  are  reported. 


TETANY.  443 


Tetany  (Tetanilla). 

Tetany  is  a  subacute  or  chronic  spasmodic  disorder  character- 
ized by  intermittent  or  persistent  tonic  contractions  beginnin<>- 
in  tlie  extremities  and  associated  witli  pareesthesiie  and  liypei^ 
excitability  of  the  motor  and  sensory  nerves. 

Etiology.— ThQ  disease  is  very  rare  in  this  country,  but  rela- 
tively common  in  Europe,  especially  in  Austria.  It  occurs  with 
frequency  during  the  second,  third,  and  fourth  years  of  life  and 
again  at  the  time  of  puberty.  Its  rate  of  frequency  then  slowly 
declines  and  it  is  very  rare  after  fifty.  It  affects'  males  much 
of tener  than  females  up  to  the  age  of  twenty,  after  that  the  differ- 
ence disappears.  It  occurs  mostly  in  the  working  classes.  In 
infants  rickets  is  often  noted.  The  exciting  causes  are  exhausting 
influences  like  diarrhoea,  lactation,  se^jsis,  fatigue,  mental  shock, 
and  fevers ;  also  exposure  to  cold  and  m  et.  Alcoholism,  dilatation 
of  the  stomach,  and  intestinal  entozoa  are  also  causes.  It  may  be 
produced  artificially  by  extirpation  of  the  thyroid  gland.  The 
disease  sometimes  appears  as  an  epidemic. 

ISymptoms. — Tetany  begins  sometimes  suddenly  with  symmet- 
rical tonic  contractions  of  the  hands ;  at  other  times  there  are  at 
first  sensations  of  numbness,  prickling  or  pain  in  the  extremities, 
with  malaise  and  perhaps  nausea ;  then  spasms  begin.  The  at- 
tacks affect  first  and  most  the  upper  extremities.  The  flexors 
of  the  forearm  and  hand  are  usually  involved;  the  fingers  are 
flexed  at  the  metacar[)0-phalangeal  joint  and  extended  at  the  other 
joints,  and  the  thumb  is  adducted,  producing  the  "  accoucheur's 
hand."  The  forearm  may  be  flexed  and  the  upper  arm  adducted. 
The  knees  and  feet  are  extended,  the  toes  flexed,  and  the  foot  in- 
verted. In  severe  cases  the  muscles  of  the  abdomen,  chest,  neck, 
and  face  are  involved.  Opisthotonos  and  dyspncDea  may  result. 
The  muscles  of  the  face  and  eyes  develop  contractions,  and  tris- 
mus sometimes  occurs  late  in  the  disease.  The  nmscles  of  the 
larynx,  oesophagus,  and  bladder  may  be  affected.  Fibrillary 
tremors  are  observed  in  the  contracted  muscles.  The  attacks  are 
accompanied  by  parsesthesise  and  cramp-like  pains.  There  may 
be  some  abolition  of  sensation  in  the  skin  of  the  parts  affected 
during  attacks.  The  cramps  last  from  a  few  minutes  to  hours  or 
days.  They  occur  during  day  and  night  and  may  wake  the  pa- 
tient from  sleep.  Fever  is  sometimes  present  in  epidemic  cases. 
The  disease  has  a  tendency  to  recurrence. 

While  it  lasts,  both  during  and  between  the  attacks  peculiar 
phenomena  are  observed  as  follows : 

1st.  Increased  Mechanical  IrritaMUty  of  Motor  Nerves— The 
motor  nerves  show  an  abnormal  irritability,  so  that  on  strikmg 
the  motor  point  a  sharp  muscular  contraction  is  brought  out. 
When  pressure  or  a  blow  is  made  on  the  face  over  or  near  the 
exit  of  the  facial  nerve  from  its  foramen,  contractions  of  the  facial 
muscles  occur,  especially  those  of  t\ie  lips.  This  is  called  the  fa- 
cial phenomenon."  Bv  pressing  on  the  artery  and  nerve  qt  a 
limb  a  tetanic  attack  can  be  produced  in  the  muscles  supp  lecL 
It  is  probable  that  it  is  the  pressure  on  the  nerve  alone  whicii 
causes  the  phenomenon  which  is  called  "  Trousseau's  symptom. 

2d.  The  electrical  irritability  of  the  muscles  and  nerves  is  m^ 
creased,  especially  to  the  galvanic  current.  Thus  a  negative^ 
pole  closure  contraction  (CaCC)  is  brought  out  by  a  very  weak; 


444  DISEASES   OF  THE  NERVOUS   SYSTEM. 

current ;  and  if  a  little  stronger,  it  causes  a  tonic  contraction  or 
cathode'  closure  tetanus  (CaCTe)  The  positive-pole  opening 
contraction  (AnOC)  may  be  tetanic,  i.e.,  (AnOTe),  and  there  may 
]3e  even  a  cathode  opening  tetanus  (CaOTe),  a  phenomenon  not 
seen  in  any  other  disease.  According  to  Gowers  there  may  be  a 
reversal  of  the  polar  formula,  so  that  a  positive-pole  closure  con- 
traction occurs  earlier  than  a  negative  (AnCC>CaCC).  This  is 
certainlv  rare. 

8d.  Art  increase  of  irritability  of  the  sensory  nerves  is  shown 
by  pressing  upon  them,  when  sensations  of  i^rickling  and  formi- 
cation appear  along  their  course.  There  is  an  increase  also  in 
the  electrical  sensibility,  shown  by  appreciation  of  very  Aveak 
galvanic  currents.  The  auditory  nerve  reacts  to  the  galvanic 
current  in  about  fifteen  per  cent  of  normal  cases,  and  then  only 
to  strong  currents  and  to  ohly  a  i^artial  extent;  but  in  tetany  it 
reacts  in  nearly  all  cases,  and  with  coniparativeh-  weak  currents 
(2  to  5  or  6  lua.)  on  anode  closure,  anode  fixed,  and  anode  open- 
uig  (AnC  Klang,  AnDKl,  AnOKl)  (Chvostek). 

The  iDhenomena  of  hyperexcitability  above  described  vary 
considerably  and  rapidly  during  the  course  of  the  disease,  and  are 
not  always  present. 

Tyjjes'of  the  Disease.— The  disease  varies  in  intensity  and  dura- 
tion. This  variation  depends  much  upon  the  cause,  and  there 
have  been  made  a  number  of  types  of  the  disease  based  on  the 
etiology.     Thus  we  have 

1.  Epidemic  or  rheumatic  tetany. 

2.  Asthenic  tetany  due  to  lactation,  diarrhoea,  exhausting  dis- 
eases, etc. 

3.  Thyroid  tetany,  due  to  removal  of  the  thyroid  gland. 

4.  Reflex  tetany  from  gastric  dilatation  and  intestinal  worms. 

5.  Latent  forms  of  tetany  in  which  the  phenomena  of  hyper- 
excitability and  paraesthesia  occur  with  very  slight  if  any  con- 
tractions, and  no  Trousseau  symptom. 

Infantile  tetany  should  perhaps  be  separated  from  other 
forms. 

Symptomatic  tetany  from  brain  disease  is  also  spoken  of. 

When  the  spasms  are  continuous  the  disease  lasts  but  a  few 
Aveeks;  when  they  are  intermittent  it  may  continue  for  months. 
Epidemic  cases  last  but  a  few  weeks.  The  disease  may  be  said 
in  general  to  last  from  a  few  weeks  to  a  few  months.  Patients  are 
liable  to  a  recurrence  on  return  of  the  exciting  cause. 

Pathology. — The  phenomena  of  the  disease  indicate  a  congested 
and  irritative  condition  of  the  gray  matter  of  the  spinal  cord. 
The  cause  of  this  state  is  evidently  in  some  cases  (epidemic  tet- 
any) an  infectious  poison;  in  other  cases  mucin  in  the  blood 
(thyroid  tetany),  and  in  other  cases  it  may  be  a  rheumatic  or 
some  other  toxic  influence.  Ergot  is  known  to  produce  symptoms 
resembling  tetany. 

In  infantile  tetany  the  irritation  is  apparently  cortical  and 
due  to  meningitis  or  to  rickets  and  the  reflex  irritation  of  disor- 
dered bowels.  It  is  doubtful  if  any  reflex  influence  can  be  invoked 
in  adults.  Tetany  is  a  functional  'disease  and  the  symptomatic 
expression  of  a  central  irritation.  This  irritation  may  be  of  differ- 
ent kinds,  hence  tetany  has  a  claim  to  be  called  a  distinct  disease 
simply  on  clinical  grounds.  It  has  no  such  definite  pathology  as 
chorea  or  epilepsy.  In  the  very  few  autopsies  Avhich  have  been 
made  no  definite  organic  lesion  has  been  found. 


TETANY.  445 

Diagnosis.— The  disease  is  usually  easily  recognized  by  the 
character  of  the  spasms,  their  symmetrical  nature,  their  course, 
and  the  phenomena  of  hyperexcitability  of  the  muscles  and 
nerves.  Trousseau's  symptom  is  found  in  no  other  disease.  The 
"  facial  phenomenon,"  the  peculiar  electrical  and  mechanical  irri- 
tability of  the  muscles  and  nerves  are  very  rare  in  other  condi- 
tions. The  sensory  irritability  and  especially  that  of  the  acoustic 
nerve  are  also  characteristic.  From  tetanus  the  disease  is  distin- 
guished by  the  intermittency  of  the  contractions,  their  feebler 
character,  the  fact  that  they  begin  in  the  extremities  and  extend 
to  the  trunk,  and  by  the  absence  of  trismus  at  least  until  late  in 
the  disease. 

Treatment. — The  cause  should  be  removed  if  possible,  lactation 
stopped,  diarrhoea  and  indigestion  corrected,  worms  expelled, 
rickets,  if  present,  attended  to.  Rest;  nourishing  food,  and  tonics 
are  indicated.  Symptomatically,  bromide  of  potash  in  doses  of 
3  iss.  to  3  ij.  daily  with  chloral  furnishes  the  surest  relief.  Hyos- 
cine  in  doses  of  gr.  y^^  n^ay  be  tried.  Inhalation  of  chloroform 
or  injections  of  morphia  are  needed  in  severe  cases.  In  nocturnal 
tetany  Gowers  advises  digitalis.  Lukewarm  baths  may  be  of 
service ;  so  also  may  ice-bags  to  the  spine.  If  electricity  is  used 
only  the  weak  galvanic  current  should  be  employed. 


CHAPTER  XXIV. 

NEURASTHENIA  (NERVOUS    EXHAUSTION)-NERVOUS 

AVOMEN. 

Neurastheis^ia  is  a  morbid  condition  of  the  nervous  system 
of  which  the  underlying  cliaracteristics  are  weakness  and  exces- 
sive irritability.  The  disorder  is  a  functional  one.  In  its  typi- 
cal forms  the  symptoms  are  distinctive. 

£'^/o/o^2/-~^6urasthenia  occurs  most  often  between  the  ages 
of  eighteen  and  thirty,  next  between  the  ages  of  thirty  and  forty, 
and  then  between  forty  and  fifty.  It  rarely,  if  ever,  begins  be- 
fore eighteen  or  after  fifty.* 

It  affects  men  and  women  almost  equally  in  this  country. 
Pure  cases  are  more  frequent  in  men,  while  atypical  forms  in 
which  there  are  complications  of  hysteria,  spinal  irritation,  and 
local  disorders  are  moi'e  frequent  in  women. 

Americans  are,  as  a  race,  much  affected  by  it!  The  cold  and 
dry  climates  of  the  temperate  zone  favor  the  development  of  the 
disorder.  So  also  do  high  altitudes  if  they  are  dry.  Hence  the 
climate  of  this  country,  as  well  as  its  civilization,  undoubtedly 
help  to  promote  the  disease.  In  the  West,  and  especially  the 
Northwest  lake  region  and  the  Colorado  plateau,  neurasthenia 
is  said  to  be  rather  more  prevalent  than  in  the  South  or  East. 

It  occurs  in  rural  as  well  as  urban  populations.  The  educated 
classes— professional  men,  business  men,  and  politicians— furnish 
a  large  contingent.  Heredity  is  a  very  important  factor  in  the 
primary  forms. 

The  exciting  causes  are  excessive  mental  strain,  anxieties,  sud- 
den shocks,  injuries,  sunstroke,  excessive  child-bearing,  sexual 
excesses— especially  masturbation— irregularities  and  excesses  in 
eating,  drinking,  and  smoking.  Overwork  does  not  cause  it,  pro- 
vided there  is  no  great  mental  worry ;  and  even  this  can  be  borne 
if  the  patient  is  regular  in  eating  and  sleeping  and  does  not  drink 
or  smoke  too  much.     In  some  .cases  it  follows  some  single  power- 

*  Among  100  consecutive  cases  there  were  53  women,  47  men.  Ages  :  fifteen  to 
twenty-five.  25  ;  twentj^-six  to  thirty-five,  38  ;  thirty-six  to  forty-five,  25  ;  forty-six 
to  fifty-five,  20  ;  fifty-six  to  sixty-five,  2.  There  are  relatively  more  cases  in  the 
adolescence  of  man  and  in  the  later  period  of  life  of  women.  Nativity  :  United 
States,  59;  Ireland,  29  ;  Germany,  12  ;  others,  9. 


NEURASTHENIA— NERVOUS   WOMEN.  447 

ful  physical  exertion.  Malarial-poisoning,  syphilis,  and  the  in- 
fective fevers  are  important  agents  in  causing  neurasthenia.  So 
also  are  lithaemic  states,  gastric  dilatation,  and  dyspepsia. 

Reflex  irritations.  There  are  many  persons,  with  delicately 
balanced  organizations,  who  only  require  some  single  depressing 
or  irritating  agent  to  put  them  in  a  pathological  state.  This  is 
the  case  in  those  neurasthenics  who  are  made  so  by  reflex  causes, 
(iiven  a  neuropathic  constitution,  neurasthenia  may  be  produced 
by  ovarian  and  uterine  disease.  Subinvolution  and  decided  me- 
chanical displacements  are  more  potent  in  causing  neurasthenia 
than  the  chronic  inflammatory  states.  Prostatic  and  urethral 
disorders,  hemorrhoids  and  fissures,  may  excite  general  neuras- 
thenic symptoms.  Chronic  middle  and  internal  ear  disease,  caus- 
ing great  tinnitus  and  partial  deafness,  often  aggravates  a  neu- 
rasthenia, if  it  does  not  excite  it.  Nasal  stenosis  and  hypertrophic 
catarrh,  acting  either  directly  or  by  disturbing  the  visual  appa- 
ratus, may  be  a  cause.  Muscular  insufficiencies  of  the  eyes,  re- 
fractive errors,  especially  hypermetropia  and  astigmatism,  are 
often  important  factors  in  the  etiology  of  neurasthenia,  but  they 
are  not  primary  or  fundamental.  Of  reflex  influences  causing 
and  keeping  up  neurastiienia,  disturbances  of  the  stomach,  in- 
testines, and  liver  are  by  all  odds  the  most  important;  next  come 
irritations  from  the  pelvic  and  generative  organs. 

Symptoms. — In  the  neurasthenic  condition  there  are  certain 
common  symptoms  which  will  be  found  in  all  cases,  but  these 
symptoms  vary  in  prominence  according  to  the  special  setting 
of  the  case.  The  modifying  elements  are  these :  (1)  age,  (2)  sex, 
and  (3)  neuropathic  constitution. 

In  ordinary  cases  the  patient  after  some  years  of  arduous  work, 
anxiety,  and  irregular  habits,  during  which  he  has  kept  himself 
continually  on  a  strain,  begins  to  have  feelings  of  nervousness, 
restlessness,  and  irritabihty  which  are  new  to  him.  He  has  trouble 
in  sleeping  and  wakes  unrefreshed ;  he  loses  interest  in  his  work, 
which  tires  him  greatly.  His  appetite  is  poor  and  his  digestion 
disordered;  he  has  vertigoes  and  peculiar  feelings  about  the 
head ;  and  he  begins  to  get  alarmed  about  himself.  The  symp- 
toms progress  until  he  finds  he  can  no  longer  work,  he  is  irritable, 
depressed,  and  discouraged,  and  finally  begins  to  take  himself  in 
hand.  In  some  cases,  after  a  sudden  fright  or  injury  and  shock, 
all  these  symptoms  develop  rapidly. 

In  younger  persons  the  history  is  somewhat  different:  the  pa- 
tient has  perhaps  indulged  in  sexual  abuse;  then  suddenly  learn- 
ing that  it  is  a  very  dangerous  practice  he  experiences  a  fright. 
He  becomes  nervous,  worried,  and  mentally  depressed.  He  too  has 
cerebral  par^esthesi*  and  insomnia;  he  loses  interest  in  his  stud- 
ies, cannot  concentrate  his  mind,  broods  over  his  early  indiscre- 


448  DISEASES   OF  THE   NERVOUS   SYSTEM. 

tions,  and  is  panic-stricken  over  every  nocturnal  emission.  Getting- 
some  comforting  assurances  and  advice  from  his  physician,  he 
improves  and  perhaps  gets  well,  but  not  infrequently  has  for 
several  years  a  train  of  disturbing  neurasthenic  symptoms.  As 
in  older  pases,  the  neurasthenia  may  come  on  suddenly  from 
shock,  violent  physical  exertion,  and  over-use  of  tobacco. 

Symptoms  in  Detail.— T\\Q  neurasthenic  iDatient  suffers  from 
a  peculiar  feeling  of  nervousness,  discomfort,  uneasiness,  and 
sense  of  unrest;  or  from  feelings  of  tension,  as  though  under  a 
stimulant.  He  loses  interest  in  his  work,  dreads  to  assume 
any  responsibility,  has  morbid  fears  regarding  his  business,  his 
sexual  function,  his  general  health,  his  future,  or  some  trivial 
subject.  Some  idea  fixes  itself  upon  him  and  he  cannot  rid  him- 
self of  it.  He  has  difficulty  in  concentrating  his  mind  on  work. 
Periods  of  depression  attack  him.  These  mental ^-st at es  vary 
much,  and  may  be  so  paroxysmal  as  to  form  "crises."  His  sleep 
is  poor,  disturbed  by  dreams,  and  he  awakes  unrefreshed;  some- 
times there  is  a  morbid  somnolence.  Slight  attacks  of  vertigo 
annoy  him. 

The  sensory  symptoms  consist  of  feelings  of  pressure  on  the 
top  of  the  head,  as  of  a  hand  or  cajD  pressing  on  the  scalp  {the 
helmet  symptom);  pain  or  weariness  in  the  back  of  the  neck; 
numbness  of  the  hands  or  feet,  creeping  sensations  up  the  back 
or  limbs,  burning  feelings  in  the  ears,  pricking  of  the  tongue,  a 
sense  of  oppression  of  the  chest  and  of  "sinking"  in  the  epigas- 
trium. These  form  what  are  termed  neurasthenic  parcesthesice. 
ZS'eurasthenics  in  about  half  the  cases  suffer  from  headaches. 
These  are  diffuse  and  frontal  or  occipital.  The  pain  is  persistent, 
worse .  after  exertion,  and  not  very  intense.  A  boring  occipital 
pain,  neckache,  and  neck  loeariness  are  very  common,  and  women 
often  have  severe  pains  along  the  spine.  Intercostal  neuralgia, 
especially  on  the  left  side,  is  common.  General  neuralgia,  aching 
of  all  the  limbs,  feeling  of  soreness  of  the  scalp  or  of  the  mus- 
cles, as  though  one  had  been  beaten,  are  often  complained  of.* 

The  Special  *S'e?^se.S'.— Neurasthenia  does  not,  as  a  rule,  cause 
very  serious  visual  troubles.  There  is  always  some  weakness  and 
increased  irritability  of  eyesight.  If  the  patient  uses  the  eyes 
nmch  these  symptoms  may  become  very  marked.  There  is  a 
feeling  of  pressure  and  discomfort  or  pain  in  the  eyeballs.  Head- 
ache comes  on.  Vision  gets  blurred;  there  are  spots  before  the 
eyes;  excessive  light  is  annoying  and  moderate  light  dazzles. 
Reading  soon  tires  and  causes  pain;  the  lids  twitch;  the  eyes 
easily  redden  and  water.     Examination  shows  in  early  life  mo- 

*  Neurasthenics  with  a  hypochondriacal  tendency  sometimes  sufifer  from  a  persis- 
tent delusional  pain  located  in  a  certain  region,  such  as  the  arm  or  back.  This  con- 
dition has  been  called  topoalgia. 


NEURASTHENIA — NERVOUS   WOMEN.  449 

bile  and  often  dilated  pupils ;  they  are  rarely  uneven ;  there  is  a 
sli£,dit  lessening  of  visual  acuity.  The  visual  field  is  normal,  but 
sensation  in  its  periphery  tires  very  easily,  so  that  after  long  test 
ing  there  is  apparently  a  concentric  limitation  of  the.field.  The 
color  sense  is  unaffected.  Muscular  insufficiencies,  especially  of 
the  internal  recti,  often  occur.  The  patient's  visual  memories 
are  lessened,  so  that  the  neurasthenic  cannot  remember  faces  and 
places  as  he  has  been  accustomed  to  do.  If  the  patient  has  any 
refractive  error,  especially  hypermetropia  or  astigmatism,  his  eye 
symptoms  are  more  marked  and  cause  him  so  much  annoyance 
that  the  general  symptoms  get  worse.  The  eye  trouble  may  thus 
keep  up  the  neurasthenia,  but  it  will  not  alone  cause  it,  and 
treatment  of  the  general  and  local  symptoms  by  attention  to 
the  eyes  alone  is  irrational  and  disappointing. 

Neurastlat»nics  are  often  over-sensitive  to  noise.  This  is  usually 
simply  due  to  the  general  mental  irritability;  but  sometimes 
there  is  a  distinct  hyperacousia,  and  slight  noises  or  even  agree- 
able music  drive  the  patient  nearly  wild. 

Subjective  disturbances  of  taste  occur  in  cases  complicated 
with  digestive  troubles. 

There  are  no  peculiarities  regarding  the  sense  of  smell  other 
than  a  general  over-sensitiveness  to  odors. 

The  general  muscular  strength  is  lessened,  and  the  patient 
very  soon  tires,  or  even  completely  collapses,  after  slight  exertion. 
Muscular  effort  or  mental  excitement  causes  a  tremor  of  the  hands; 
often  this  is  a  persistent  symptom.  This  tremor  is  "fine "and 
vibratory  in  character  (about  twelve  to  the  second).  The  skin 
reflexes  and  tendon  reflexes  are  exaggerated.  There  is  a  slight 
amount  of  "static  ataxia,"  i.e.,  the  patient  sways  more  when 
standing  erect  with  closed  eyes  than  when  his  eyes  are  open,  the 
reverse  being  the  case  in  healthy  people.  The  eyelids  quiver 
when  tightly  shut.  The  general  nutrition  is  not  usually  much 
affected ;  if  anything,  the  patient  loses  weight. 

There  is  decided  evidence  of  loss  of  vasomotor  tone.  This  is 
shown  in  the  cold  hands  and  feet,  tendency  to  hyperidrosisof  the 
palms  and  soles,  flushings  and  pallor  of  the  face,  sense  of  fulness 
in  the  head,  variations  in  the  specific  gravity  and  amount  of  the 
urine.  Palpations  of  the  heart  easily  occur,  and  examination  of 
the  pulse  shows  it  to  have  frequent  and  rapid  'variations  in  ten- 
sion, there  being  generally  abnormal  lowering.  The  vasomotor 
reaction  produced  by  drawing  a  blunt  instrument  over  the  skin 
is  more  pronounced  than  in  healthy  people.  A  deep  red  hne 
appears  after  pressure,  which  lasts  twenty  or  thirty  minutes.  In 
rare  cases  an  artificial  urticaria  can  be  produced.  The  phe- 
nomenon is  called  "  dermography." 

The  sexual  functions  are  weakened  and  irritable,  and  inter- 
29 


450  DISEASES   OF  THE  NERVOUS  SYSTEM. 

course  is  imperfect  and  exhausting.  In  the  younger  and  more 
neuropathic  cases  emissions  occur,  and  morbid  fears  regarding 
this  function  annoy  and  depress  the  patient.  These  fears  and 
introspections  occupy  the  mind  and  furnish  to  the  patient  the 
belief  that  all  his  troubles  hinge  upon  his  early  indiscretions  or 
his  present  rather  frequent  emissions.  Sometimes  thei-e  is,  in 
fact,  such  an  extreme  degree  of  seminal  loss  as  to  keep  up  the 
neurasthenic  state.  The  genitals  become  relaxed,  there  is  a  slight 
discharge  of  urethral  and  prostatic  secretion,  especially  after 
stools.  In  women  dysmenorrhoea,  menorrhagia,  and  slight  irreg- 
ularities in  menstruation  occur. 

The  digestive  organs,  including  the  metabolic  tissues  of  the 
liver,  are  almost  always  at  fault.  There  are  a  great  many  ner- 
vous affections  of  the  stomach,  such  as  gastralgia,  gastroxynis, 
muscular  atony,  etc.  These  disorders  may  be  associated  with 
neurasthenia  and  be  the  cause  of  part  of  the  trouble.  The 
gastric  trouble  in  rare  cases  may  even  be  primary,  or  hold  equal 
rank  with  the  nerves  in  the  symptom  complex.  Such,  however, 
is  by  no  means  the  rule.  The  nervous  asthenia  leads  to  the 
gastric  dyspepsia,  and  this  again  makes  the  neurasthenia  worse. 
The  special  symptoms  caused  by  the  stomach  complication  are 
a  sense  of  congestion  and  f-ulness  in  the  head,  dizziness,  headache, 
palpitation,  and  abdominal  pulsation ;  belching,  feeling  of  pres- 
sure and  fulness  in  the  epigastrium,  nausea,  pyrosis,  anorexia, 
and  alterations  of  taste. 

The  hepatic  functions  are  weakened  and  slowed  down ;  and  a 
neurasthenic  liver  is  one  of  the  common  and  fundamental  condi- 
tions of  the  neurasthenic  state.  This  produces  intestinal  dyspep- 
sia, fermentation,  and  constipation.  The  blood  absorbs  an  excess 
of  ptomaines  and  imperfectly  oxidized  products,  causing  many  of 
the  general  nervous  symptoms  already  described,  such  as  the 
parsesthesi{je,  dizziness,  somnolence,  and  head  pressure.  This 
condition  is  called  "  lithaeinia,'''  or  nervous  gout.  It  is  not  so  much 
a  distinct  diathesis,  like  the  gouty  or  rheumatic,  as  it  is  a  morbid 
condition  from  accumulation  of  metabolic  products. 

The  intestinal  movements  are  sluggish,  and  the  patient  suffers 
from  flatulence  and  feelings  of  distention.  Sometimes  there  is  a 
nervous  diarrhoea  alternating  with  constipation.* 

Sometimes  the  striking  sj-mptom  in  a  neurasthenic  patient  is 
the  disturbance  in  the  heart's  action.     This  shows  itself  in  feeble- 

*  Enferoptosis  and  Neurasthenia.— A 'form  of  neurasthenia  has  been  rlescribed 
by  Glennard  under  the  head  of  enteroptosis,  or  prolapse  of  the  abdominal  viscera. 
This  occurs  in  women  who  have  lax  abdominal  walls,  with  some  descent  of  the 
stomach  and  intestines,  and  stretching  of  the  suspending  ligaments  and  mesenterj'. 
In  these  cases  there  is  usually  some  dilatation  of  the  stomach,  atony  of  the  intestinal 
walls,  and  consequent  symptoms  of  inuigestion. 


NEURASTHENIA— NERVOUS  WOMEN.  451 

ness  of  the  heart  beat  and  heart  sounds  and  sinallness  of  the 
pulse.  Palpitation  occurs  on  slight  exertion,  and  there  may  be 
pseudo-anginal  attacks,  or  sensations  of  oppression  and  discom- 
fort over  the  heart.  The  patient  also  complains  of  feeling  the 
beating  of  the  heart,  perhaps  all  over  the  body.  The  pulse  may 
be  very  slow,  especially  in  the  morning.  General  neurasthenic 
symptoms  are  present.  Patients  with  heart  disease  are  liable  to 
be  especially  annoyed  by  various  evidences  of  heart  weakness 
and  irregular  action. 

The  respirations  are  normal  in  number,  but  shallow,  and  de- 
ficient respiratory  expansion  may  be  noted.  A  feeling  of  pres- 
sure on  the  chest  is  often  described. 

The  younger  patients  and  women  are  generally  anaemic,  but 
in  middle-aged  adults  this  is  not  so;  the  face  is  full  and  ruddy 
and  the  mucous  membranes  of  good  color. 

The  urine  in  the  young  and  neuropathic  cases  is  variable  in 
specific  gravity,  but  generally  low,  1.012  to  1.018;  under  excite- 
ment it  may  drop  to  1.002.  Phosphates,  earthy  and  alkaline,  are 
excreted  in  excess,  wdiile  the  nitrogenous  solids  are  often  dimin- 
ished in  amount.  In  older  cases  with  more  digestive  and  hepatic 
disturbance  and  lith^mia  the  urine  is  heavy,  1.024  to  1.036,  quite 
acid,  and  contains  at  times  excess  of  phosphates  and  urates.  Ox- 
alates are  also  found,  but  indicate  no  more  than  does  excess  of 
urates,  i.e.,  a  lithtemic  state.  The  amount  of  urine  passed  is 
variable.  At  times  there  is  polyuria,  but  on  the  whole  the  total 
amount  is  below  normal. 

The  Modified  Tx-p-K^.— Neurasthenia  in  Adolescence— De- 
generative Neurasthenia.— When  neurasthenia  begins  under  the 
age  of  twenty-five,  there  is  a  more  distinct  evidence  of  neuro- 
pathic constitution.  The  mental  symptoms  are  more  marked 
and  approach  those  of  hypochondriasis.  There  is  greater  de- 
pression and  greater  introspection.  'Morbid  sexual  ideas,  fear  of 
impotence,  remorse  over  past  indiscretions  in  venery ;  spermato- 
phobia;  morbid  fears  of  contamination,  of  being  forever  inca- 
pacitated for  procreation  or  sound  mental  and  physical  work, 
annoy  the  patient.  The  general  nutrition  is  affected.  He  is 
anaemic,  has  cold  extremities,  clammy  hands,  dilated  pupils.  His 
urine  is  of  low  specific  gravity  and  contains  an  excess  of  phos- 
phates, both  earthy  and  alkaline.  Pains,  parsesthesiae,  vertigo, 
head  pressure,  and  gastric  disturbances  are  not  so  marked. 

This  type  of  neurasthenia  is  often  described  as  "  sexual "  or 
as  "  primary. ''  It  is  really  a  manifestation  of  neurotic  degeneracy, 
and  may  be  looked  upon  as  an  abortive  form  of  paranoia.  When 
more  fully  developed  the  degeneracy  shows  itself  by  such  symp- 
toms as  fixed  ideas,  and  morbid  fears  such  as  agoraphobia  (fear  of 
open  places) ;  claustrophobia  (fear  of  closed  places) ;  mysophobia 


452  DISEASES   OF   THE   NERVOUS   SYSTEM. 

(fear  of  eontainination) ;  pathophobia  (fear  of  disease);  anthro- 
pophobia  (fear  of  society).  Abortive  forms  of  folie  du  dotcte,  or 
the  doubtness-niadness,  are  also  present  in  this  type. 

neurasthenia  of  Women  in  Adolescence. — Young  nervous 
women  are  usually  anaemic,  dyspeptic,  and  constipated;  their 
nutrition  is  not  good;  they  are  thin;  they  excrete  large  quanti- 
ties of  limpid  urine ;  they  often  have  spinal  pains  and  headaches 
of  the  migrainous  and  other  types,  and  almost  all  of  them  suffer 
more  or  less  at  the  time  of  menstruation.  They  have  mobile 
pupils.  Their  special  senses  are  keen,  to  the  point  of  hypertes- 
thesia.  The  heart  is  irritable;  the  vasomotor  centres  are  un- 
stable. They  have  cold,  clammy  extremities.  They  are  vivacious, 
quick,  observant,  impatient,  living  on  their  "  nerves,"  fond  of 
excitement,  and  indulging  in  amusements,  for  which  they  pay 
the  penalty  by  prolonged  exhaustion. 

Neurasthenia  of  Women  in  Early  and  21iddle  Life.— It  is  the 
nerv^ous  women  between  the  ages  of  twenty-five  years  and  forty 
who  make  up  the  majority  of  female  neurasthenics.  They  are, 
so  to  speak,  the  wreckage  of  the  young  nervous  women  and  of 
healthy  young  women  for  whom  the  burden  of  life  and  domes- 
ticity^ was  too  heavy.  For  they  are  usually  married  and  are  some- 
times prolific  mothers,  though  the  worst  cases  are  the  childless  or 
the  "  monopsedic.*'  The  principal  symptoms  from  which  they 
suffer  are  nervousness,  weakness,  insomnia,  dyspepsia,  morbid 
and  depressing  ideas,  headaches  and  neuralgias,  vertigo,  tremor, 
and  vasomotor  symptoms. 

They  often  have  migraine  and  backaches,  but  they  do  not 
have  fully  developed  spinal  irritation ;  they  suffer  from  peculiar 
feelings  of  numbness  in  different  jDarts  of  the  body ;  they  often 
exhibit  a  marked  tremulousness  of  the  hands,  Avhile  the  cold  ex- 
tremities and  wet  hands  are  not  so  commonly  observed.  They 
become  easily  exhausted.  They  are  excessively  nervous  and  irri- 
table ;  slight  noises  will  startle  them;  they  cannot  read  long  with- 
out gettmg  a  pain  in  the  head ;  they  suffer  from  time  to  time  from 
attacks  of  prof  ound  mental  depression,  and  often  have  fixed  ideas 
of  a  melancholy  type;  they  have,  at  times,  "crises,"  or  "nervous 
storms,"  which  may  take  the  form  of  a  headache,  a  fit  of  blues, 
or  a  lively  domestic  disturbance.  The  dyspepsia  they  have  is  not 
of  a  very  severe  type ;  it  is  usually  accompanied  with  fermenta- 
tion and  acid  eructations.  The  urine  always  varies  in  quantity 
and  specific  gravity.  Sometimes  they  will  pass  large  amounts  of 
limpid  urine.  Such  women  are  often  called  hysterical,  but  the 
somatic  and  asthenic  symptoms  are  more  prominent  than  the 
psychical,  and  they  do  not  have  hysterical  stigmata. 

Climacteric  Neurasthenia.— At  the  climacteric  in  women,  and 
sometimes  at  a  corresponding  age  in  men,  neurasthenic  symptoms 


NEURASTHENIA— NERVOUS  WOMEN.  453 

develop.  In  women  these  symptoms  are  mostly  of  a  vasomotor 
character.  Hot  flashes,  flushing,  nervous  irritai3ilitv,  poor  sleep 
oj-  morbid  somnolence,  pains  in  the  back  and  head,  sensations  of 
fainting  and  sinking,  tendency  to  mental  depression,  are  among 
the  chief  symptoms  in  women,  among  whom  this  trouble  may  be 
regarded  as  a  climacteric  neurasthenia.  Evidences  of  vascular 
tension  and  of  beginning  arterial  degeneration  will  be  found. 
In  men  the  symptoms  do  not  greatly  differ  from  those  of  the 
ordinary  type.  Both  in  men  and  women  this  form  of  neurasthe- 
nia runs  a  comparatively  short  and  favorable  course. 

Course  and  Z>i^raif/o7Z.— Neurasthenia  is  a  chronic  disorder 
and  lasts  from  one  to  five  or  ten  years,  depending  largely  upon 
treatment  and  habits  of  life.  The  forms  occurring  at  the  climac- 
teric are  the  shortest  and  most  favorable,  those  occurring  in  early 
middle  life  come  next,  while  those  fovms  which  develop  in  youth, 
if  dependent  upon  neurotic  constitution,  are  the  most  chronic. 
The  disease  lasts  longer  in  women  than  in  men. 

P«^/io^^?/,— Neurasthenia  is  a  condition  in  which  the  nutri- 
tion of  the  nerve  cells  is  primarily  at  fault.  These  cells  have  lost 
their  power  of  building  themselves  up  into  stable  compounds. 
They  easily  break  down  under  slight  irritation,  and  send  out 
consequently  but  feeble  impulses.  These  facts  are  indicated  by 
the  terms  "  irritability"  and  "  weakness.'"  It  is  thought  by  some 
that  this  dystrophic  condition  especially  involves  those  parts 
which  make  up  the  vasomotor  neuro-mechanism ;  and  if  this  be 
so,  it  is  the  nervous  tissue  of  the  medulla  and  central  parts  of 
the  spinal  gray  matter  that  are  the  most  involved.  There  is  lit- 
tle doubt,  however,  that  the  cortical  gray  matter  and  higher  cen- 
tres of  the  brain  are  also  implicated,  for  the  mental  symptoms  are 
always  prominent.  It  is  certain  that  the  peripheral  nerves  are 
not  i3rimarily  at  fault.  Since  it  has  been  shown  that  the  sympa- 
thetic system  is  only  an  outflow  from  the  cerebro-spinal,  and  that 
many  of  its  ganglia  are  rudimentary  and  functionless,  the  idea 
that  neurasthenia  is  located  in  the  "  ganglia  "  of  this  system  be- 
comes quite  untenable.  The  view  that  neurasthenia  is  usually 
lithsemia  and  of  gastro-hepatic  origin  I  have  tested  thoroughly. 
Patients  rarely  get  any  better  by  treatment  based  on  this  hy- 
pothesis. 

Vascular  changes  in  the  nervous  sj^stem  take  place.  These 
are  of  the  nature  of  cerebral  hyper^emia,  and  probably  hyper- 
emia of  the  spinal  gray  matter.     More  rarely  there  is  ansemia. 

The  importance  and  dominance  of  the  vasomotor  changes  in 
the  skin  and  internal  viscera  have  been  already  alluded  to  under 
the  head  of  symptoms.  This  vasomotor  disturbance  is  one  char- 
acterized by  a  weakness  of  the  inhibitory  vasoconstrictor  centres. 
As  a  consequence  the  vessels  dilate  and  contract  irregularly  in 


454  DISEASES   OF  THE   NERVOUS   SYSTEM. 

the  different  systems  of  the  body.  Furthermore,  they  do  not  re- 
spond normally  to  the  stimulus  of  functioning.  When  brain  or 
stomach  acts  it  calls  for  a  definite  and  well-regulated  supply  of 
blood;  in  neurasthenia  it  does  not  get  it,  and  hence  the  morbid 
symptoms. 

The  nervous  system  controls  the  metabolic  processes  of  the 
body,  which  are  especially  active  in  the  liver,  spleen,  and  mus- 
cles. In  neurasthenia  this  process  is  disturbed,  and  the  liver 
particularly  is  atonic  or  sluggish.  This  disturbance  has  already 
been  described  under  the  head  of  digestion. 

In  other  cases  metabolism  is  affected  differently ;  it  seems  to 
be  simply  too  slow.  The  tissues  do  not  build  up  and  break  down 
at  a  normally  rapid  rate.  The  urine  is  of  low  specific  gravity 
and  the  total  solids  excreted  are  less  than  normal. 

One  exception  to  this  slowness  of  metabolism  occars.  In  all 
forms  of  neurasthenia  there  is  a  tendency  to  excessive  breaking 
up  and  discharge  of  the  phosphates,  both  alkaline  and  earthy. 

Diagnosis. — Neurasthenia  must  be  differentiated  from  simple 
nervousness,  degenerative  forms  of  insanity,  such  in  particular 
as  paranoia,  from  hypochondriasis,  from  melancholia,  hysteria, 
and  spinal  irritation. 

Nervousness  may  be  a  natural  characteristic,  a  part  of  the 
temperament.  As  long  as  the  patient  does  not  suffer  and  is  not 
incapacitated  from  work  and  enjoyment,  we  can  somewhat  arbi- 
trarily say  it  is  not  neurasthenia. 

Peculiar  sexual  perversions,  doubting  mania,  pronounced 
forms  of  morbid  fears,  may  be  associated  with  some  neurasthenic 
symptoms,  but  the  diseases  mentioned  are  essentially  iDsychical 
disorders  and  dependent  on  a  congenitally  deficient  brain.  The 
hereditary  history  is  usually  bad.  The  clearness  and  dominance 
of  the  mental  symptoms  are  sufficient  for  a  diagnosis.  The  same 
remarks  apply  to  hypoGhondriasis.  The  mental  depression 
and  fixed  ideas  are  altogether  disproportionate  to  the  other 
symptoms. 

In  melancholia  there  are  pallor,  anaemia,  loss  of  flesh,  ano- 
rexia, insomnia,  coated  tongue,  and  constipation,  often  a  lowering 
of  temperature,  a  profound  and  constant  mental  depression. 
This  must  often  be  looked  out  for  in  Avomen  at  the  time  of  the 
climacteric.  The  mild  types  of  melancholia  are  found  oftener  in 
women. 

Hysteria  may  complicate  neurasthenia.  It  is  found  much 
oftener  in  women,  but  in  the  neuroses  following  shocks  and  inju- 
ries it  is  seen  in  men.  Hysteria  is  essentially  a  mental  disease 
involving  the  emotional  faculties  and  the  will,  while  the  bodily 
condition  may  be  good.  It  is  characterized  by  various  crises  of  a 
convulsive  or  emotional  character.     There  are  certain  stigmata 


1 


NEURASTHENIA— NERVOUS   WOMEN.  455 

almost  always  present  which  enable  one  to  recognize  it.  These 
are  the  anaesthesiae  of  the  special  and  gerieral  senses. 

Spinal  irritation  is  usually  a  complication  of  neurasthenia  or 
hysteria,  and  presents  easily  distinguishable  characters.  It  may 
occur  quite  independently  of  the  distinctive  symptoms  of  the 
neurasthenic  state. 

The  jyrognosis  is  in  general  favorable.  Most  patients  get  well, 
or  practically  well,  so  that  with  care  they  can  enjoy  life  and  at- 
tend to  its  duties.  But  the  patient  almost  always  has  some  re- 
minders that  he  cannot  overtax  himself  or  do  quite  as  much  as 
can  a  person  of  strong  nerves.  This  is  especially  true  up  to  the 
age  of  forty-five  or  fifty.  The  lessened  sensibility  of  the  nerves 
in  the  declining  years  then  comes  to  his  help ;  he  gets  the  benefit 
of  his  past  years  of  regularity  and  temperance ;  his  late  years  are 
his  best,  and  he  lives  to  enjoy  many  of  them.  Neurasthenics,  if 
they  get  well,  get  old.  ^N^eurasthenia  does  not  lead  to  insanity 
or  epilepsy  or  organic  disease;  but  it  may  be  supplanted  for  a 
time  by  an  asthma  or  severe  neuralgia  or  other  neurosis. 

Treatment. — It  is  of  the  first  importance  for  the  physician  to 
get  a  firm  control  of  the  patient.  This  can  only  be  done  by  mak- 
ing the  most  careful  and  scrutinizing  examination,  and  by  so 
acting  as  to  make  the  patient  feel  that  he  understands  his  case 
and  is  master  of  its  character.  The  patient  should  then  have 
his  course  of  treatment  laid  out  for  him.  If  he  does  not  follow 
it  strictly  all  treatment  should  be  stopped.  Women  are  harder 
to  manage  at  their  homes  'than  men,  and  it  is  better  to  isolate 
them  somewhere  if  possible. 

Rest  or  lessening  of  business  and  domestic  duties  is  fundamen- 
tal. Travelling  is  bad,  but  the  patient  can  be  sent  to  stay  at  such 
places  as  the  Azores,  West  Indies,  Bermuda,  or  to  some  special 
point  in  Southern  Europe.  A  trip  along  our  great  lakes,  camping 
out,  or  long  sea  voyages  in  rather  warm  climates  are  to  be  advised. 

The  diet  should  be  rather  nitrogenous  than  otherwise,  but 
fats  and  green  vegetables  and  certain  fruits  may  be  added.  Sugars 
and  starches  are  to  be  avoided,  though  malt  preparations  usually 
agree.  The  nutrition  of  the  patient  cannot  be  too  carefully 
watched.  He  should  be  weighed  and  sometimes  fattened,  using 
water,  malt,  oil,  and  cream  for  this  purpose.  The  amount  and 
specific  gravity  of  urine  must  be  noted,  and  his  diet  regulated 
accordingly.  Neurasthenic  patients  usually  drink  too  little  water 
or  else  too  much  at  meal-time.  Water  should  be  drunk  between 
meals  or  half  an  hour  to  an  hour  before  meals.  Neurasthenics 
need  to  be  properly  fed,  but  not  to  be  stuffed.  In  many  cases  a 
low  diet,  but  one  perfectly  digestible,  is  most  indicated.  Meals 
should  be  taken  at  fixed  hours. 

A  cold  sponge  bath,  or  a  shower  or  a  strong  jet  of  cold  water 


456  DISEASES  OF  THE  NERVOUS  SYSTEM. 

on  tlie  back,  or  a  cold  plunge,  are  measures  that  are  almost  in- 
variably indicated.  In  irritable  cases  the  Avet  pack  for  three- 
quarters  of  an  hour,  followed  by  the  cool  wash-off,  has  a  very 
quieting  effect.  A  lukewarm  bath  at  95'  to  98'  at  night  for  half 
an  hour  relieves  the  paraesthesise  and  insomnia.  The  skin  should 
have  a  thorough  rubbing  every  day. 

Respiratory  exercises  for  expanding  the  lungs,  light  exercise, 
such  as  swinging  clubs  or  dumb-bells,  throwing  balls,  swinging 
from  horizontal  bars  or  rings,  bicychng,  horseback-riding,  tennis, 
rowing,  fishing,  etc.,  should  be  encouraged.  The  exercise  should 
not  be  severe ;  it  should  be  interesting,  it  should  be  done  in  fresh 
air,  and  it  should  bring  into  play  the  lungs  and  arms  more  than  the 
legs.     Walking  does  little  good,  though  it  is  better  than  nothing. 

The  drugs  of  most  use  in  neurasthenia  are  the  bromides, 
nux  vomica,  mineral  acids,  quinine,  iron,  valerian,  the  hyp- 
notics, and  saline  and  alkaline  laxatives.  Many  drugs  of  re- 
pute, such  as  arsenic,  phosphorus,  zinc,  cannabis  indica,  bella- 
donna, are  of  no  especial  value. 

The  bromide  of  sodium  or  potassium  should  be  given  in  doses 
of  fifteen  or  twenty  grains  three  times  daily;  it  should  be  kept 
up  for  only  a  week  and  thei;i  gradually  reduced  to  one-half  dose 
once  daily.  At  the  same  time  the  patient  may  be  given  a  tonic 
mixture  containing  quinia,  strychnia,  and,  if  indicated,  iron. 
Quinine  must  be  given  carefully,  as  it  causes  increase  of  nervous- 
ness in  many. 

Phosphoric  and  muriatic  acids  are  the  two  mineral  acids  most 
often  of  use.  These  acids  are  usually  better  given  after  meals. 
In  mild  cases  a  tonic  and  sedative  may  be  combined  by  giving 
a  mixture  containing  hydrobromic  acid  with  nux  vomica  and 
pepsin.  As  a  matter  of  convenience  the  bromide  of  lithium  in 
five-grain  doses  may  be  put  up  in  capsules  with  hydrobromic 
acid  and  glycerin.  Tincture  of  nux  vomica  sometimes  acts  bet- 
ter than  strychnia,  but  it  must  be  given  in  large  doses— tti  x.  in- 
creased to  m  XXV.  or  m  XXX.  The  saccharated  carbonate  or  albu- 
minate of  iron,  or  Eland's  pills,  if  given,  should  be  given  generously, 
i.e.,  in  doses  of  thirty  grains  daily. 

The  insomnia,  if  present,  yields  usually  to  the  bromides,  but 
will  return  unless  further  treatment  is  given.  After  using  bro- 
mides for  a  time,  therefore,  it  is  better  to  substitute  half  a  drachm 
of  sulphonal  or  of  chloralamide,  or  gr.  xv.  of  chloral,  or  a  drachm 
of  paraldehyde.  Lukewarm  baths  (95'  to  100")  may  be  used  as 
adjuvants.  The  dose  of  the  hypnotic  should  be  gradually  less- 
ened and  not  suddenly  and  irregularly  stopped. 

If  the  patient  is  lithsemic  or  arthritic,  he  should  be  made  to 
drink  an  alkaline  water,  like  the  lithia  waters  or  Carlsbad,  and 
his  bowels  are  better  kept  open  by  means  of  salines  than  pills. 


NEURASTHENIA — NERVOUS  WOMEN.  457 

Antipyrin,  potassium  bicarbonate,  and  the  salicylates  often  help 
painful  symptoms  in  such  eases. 

In  those  forms  of  nervousness  in  which  there  is  a  great  deal  of 
melancholy  quinine  is  of  use,  and  when  quinine  cannot  be  borne  in 
ordinary  doses  the  patients  will  often  tolerate  Warburg's  tincture. 

In  cases  in  which  there  is  a  good  deal  of  cerebral  hyperemia 
and  occipital  pain,  aconitia  and  cupping  or  burning  at  the  back 
of  the  neck  are  indicated. 

In  young  patients  witli  seminal  troubles,  atropia,  camphor, 
and  turpentine  may  be  added  to  quieting  mixtures  at  night.  In 
those  with  an  hysterical  element,  five  to  ten  grains  of  valerianate 
of  zinc  should  be  given  daily  for  three  or  four  weeks. 

Young  nervous  women  require  tonics,  such  as  Warburg's  tinc- 
ture and  large  doses  of  Blaud's  pills,  together  with  systematic 
cold  applications  to  the  spine;  and,  for  certain  periods,  the  bro- 
mides, valerian,  and  nervines  of  that  character.  Marriage  may 
help  them ;  but,  unfortunately,  these  women  are  sometimes  very 
prolific.  The  cultivation  of  athletics  Avould  be  the  greatest  boon 
that  young  women  could  receive.  All  girls  should  be  examined, 
shown  what  deficiencies  exist,  and  taught  to  make  them  up  by 
gymnastic  exercise. 

In  neurasthenic  women  with  painful  backs  or  with  a  hysteri- 
cal complication,  much  can  be  said  for  electricity.  General  and 
spinal  galvanization  and  the  static  sparks  are  the  specially  effi- 
cient forms.  General  electrization  is  a  decided  mechanical  tonic 
and  useful  in  almost  all  forms  of  neurasthenia;  but  it  is  more 
useful  in  cases  in  early  life,  in  women,  in  the  asthenic,  and  in 
those  with  spinal  pains.  Electrical  treatment  should  be  given 
three  or  four  times  weekly  for  about  six  weeks,  then  suspended. 

Massage  has  no  special  or  curative  value  in  neurasthenia,  ex- 
cept as  part  of  the  rest-cure.  Mildly  used  it  soothes  and  quiets 
many  patients  and  has  a  symptomatic  use.  Vigorous  massage  is 
injurious. 

The  rest-cure,  as  described  by  Dr.  Weir  Mitchell,  is  indicated 
for  a  certain  class  of  neurasthenic  Avomen  with  decided  impair- 
ment of  nutrition  and  a  complicating  hysteria. 

The  discovery  and  treatment  of  the  reflex  irritations  are  im- 
portant. After  the  stomach  and  liver,  the  pelvic  organs  and  the 
eyes  are  the  most  fruitful  sources  of  trouble. 

The  Sexual  Neuroses  aivd  Psychoses.   , 

Of  the  above  disorders  the  neurologist  has  to  deal  chiefly  with 
the  vicious  habit  of  masturbation  (which  may,  however,  be  also 
a  manifestation  of  disease)  and  the  sexual  neuroses,  spermator- 
rhoea and  impotence. 


458  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Masturbation  axd  Spermatorrhcea.— Masturbation  is  the 
name  given  to  the  vicious  habit  of  artificiaiiy  exciting  the  sexual 
orgasm.  It  is  very  common  among  boys  and  less  common  but 
present  among  girls  and  adult  men  and  women.  It  is  usually 
only  a  vice  due  originally  to  low  associations  and  teachings 
among  children.  In  some  cases  it  is  a  disease  or  the  symptom  of 
a  neurotic  or  insane  constitution. 

Etiology. — It  is  most  common  between  the  ages  of  fourteen 
and  eighteen,  but  may  begin  earlier.  Even  infants  and  very 
young  children  sometimes  masturbate,  usually  as  the  result  of 
some  local  irritation  which  leads  them  to  rub  the  genitals.  A 
tight  prepuce,  eczema,  or  worms  may  lead  to  the  habit,  but  it 
is  usually  taught  by  a  companion.  The  practice  sometimes  at- 
tacks schools  almost  like  an  epidemic,  for  in  every  institution 
a  certain  per  cent  of  the  boys  are  sexually  precocious  or  vicious, 
while  the  others  are  ignorant  and  innocent  of  the  evils  of  the 
practice.'  Masturbation  is  relatively  rare  after  twenty,  but  is 
practised  by  some  throughout  life  even  up  to  old  age. 

Results. — Masturbation  as  ordinarily  practised  leads  after  a 
time  to  a  feeling  of  malaise,  mental  depression,  disinclination  to 
work,  study,  or  to  enjoy  one's  self  as  before.  The  appetite  is  a 
little  impaired,  the  extremities  easily  get  cold  and  j^erspire  read- 
ily. Peculiar  numb  feelings  are  felt  in  the  hands  and  feet.  There 
is  an  unnatural  nervousness  and  irritability,  and  the  power  of 
concentrating  the  mind  is  a  little  weakened.  The  patients  often 
have  dilated  pupils  and  hyperaesthetic  skin.  After  a  time  noc- 
turnal emissions  occur.  The  organs  become  irritable  and  slight 
excitement  causes  erections.  These  symptoms  may  be  slightly 
marked  and  pass  away  in  a  day  or  two,  or  until  another  indul- 
gence occurs. 

Masturbation  is  sometimes  done  to  an  extraordinary  extent, 
even  daily  or  twice  daily  for  a  considerable  time.  After  a  while 
the  young  man  begins  to  find  that  he  is  not  well  and  realizes 
that  this  habit  is  hurting  him.  Then  if  he  be  sensible  and  of 
healthy  constitution  he  stops.  Others  are  frightened  out  of  it  by 
friends  or  by  reading  the  terrorizing  stories  printed  in  quack  ad- 
vertisements and  circulars.  Sometimes  the  fright  thus  caused 
leads  the  unhappy  youth  into  a  condition  of  hypochondriasis, 
which  is  helped  on  by  the  occurrence  of  nocturnal  pollutions  and 
the  nervous  debility  resulting  from  his  past  indiscretions.  In 
other  cases  in  which  there  is  a  decided  neurotic  history,  a  genuine 
neurasthenia  of  a  sexual  type  develops  and  annoys  the  patient 
for  years. 

Masturbation  rarely  leads  to  insanity  and  is  oftener  a  symp- 
tom than  a  cause  of  such  disorder.  It  is  occasionally  the  cause 
of  epilepsy.     When  this  is  the  case  the  convulsive  attacks  are 


NEURASTHENIA— NERVOUS   WOMEN.  459 

likely  to  put  on  a  hysteroid  phase  and  are  accompanied  with 
peculiar  co-ordinated  convulsions  and  emotional  disturbance. 
Masturbation  is  the  common  cause  of  hystero-epilepsy  in  women. 

Diagnosis.— Isiiu^Y  victims  of  the  masturbation  habit  who 
have  come  to  recognize  its  evils  and  tried  to  stop  it  develop  a 
hypochondriacal  condition,  and  feel  sure  that  there  is  something 
in  their  faces  which  reveals  to  the  world  their  trouble.  This  is 
not  the  case.  But  there  is  a  certain  physiognomy  which  in  a 
measure  characterizes  the  masturbator  to  such  an  extent  that 
an  experienced  observer  can  detect  it.  The  pale,  pasty  complex- 
ion, moist,  furtive  eye,  dilated  pupil,  listless,  restless,  and  de- 
pressed manner,  the  wet,  flabby  palms  and  hyperaesthetic  skin, 
all  help  to  tell  the  story.  Locally  the  penis  is  often  reddened  and 
more  or  less  turgid,  the  scrotum  relaxed,  and  a  varicocele  may  be 
present.  Examination  of  the  urine  may  reveal  spermatozoa. 
The  urine  also  is  almost  always  of  rather  low  specific  gravity, 
and  contains  a  great  excess  of  phosphates,  both  earthy  and  alka- 
line. 

Treatment. — The  patient  must  be  told  plainly  the  necessity  of 
stopping  the  practice.  He  must  be  impressed,  but  not  terrorized. 
He  should  be  kept  out  of  doors  at  vigorous  physical  exercise,  for 
sedentary  and  solitary  work  is  always  bad  for  such  cases.  He 
should  be  made  to  take  cold-water  baths  and  should  sleep  on  a 
hard  bed  with  light  covering.  He  had  better  sleep  with  some 
one  whose  presence  may  exercise  a  controlling  influence.  He 
should  not  eat  heartily  at  night,  never  just  before  going  to  bed, 
and  what  is  still  more  important,  he  should  not  drink  before 
going  to  bed.  Sometimes  it  is  well  to  have  him  wakened  at  an 
early  hour  in  the  morning,  when  he  should  empty  his  bladder; 
for  emissions  occur  often  early  in  the  morning  and  are  promoted 
by  the  irritation  of  a  full  bladder. 

Locally  cold-steel  sounds  may  be  introduced  and  allowed  to 
remain  for  ten  minutes  three  or  more  times  a  week,  or  the 
psychophor  or  Ultzman's  short  catheter  may  be  used.  In  bad 
cases  w^ith  a  great  deal  of  prostatic  irritation,  local  applications 
of  nitrate  of  silver  are  needed.  Internally  a  mixture  of  tinct. 
opii,  tinct.  camph.,  and  tinct.  lupulin  may  be  given  at  night,  the 
ingredients  being  somewhat  varied  in  amount  to  suit  the  case. 
Bromides,  chloral,  atropia,  and  salix  nigra  are  also  drugs  which 
al-e  often  useful.  The  mechanical  measures  which  have  been 
devised  for  preventing  erections,  such  as  rings  with  sharp  teeth, 
are  rarely  needed  and  rarely  useful.  They  may  even  do  harm  by 
directing  the  mind  to  the  affected  function. 

I  do  not  believe  it  right  for  the  physician  to  prescribe  fornica- 
tion. It  is  not  safe  nor  curative,  apart  from  the  moral  aspect  of 
the  matter.     It  has  always  struck  me  also  as  pretty  small  busi- 


460  DISEASES   OF   THE   NERVOUS   SYSTEM. 

ness  for  a  man  to  purposely  select  a  wife  to  relieve  him  of  the 
results  of  a  weak  will  and  vicious  sensual  indulgence.  If  mar- 
riat'-e  comes  in  the  natural  course  of  events,  as  it  often  does,  so 
mu'ch  the  better.  But  to  select  a  wife  as  a  remedial  agent  for 
masturbation  is  unjust  to  the  woman  and  a  confession  of  moral 
and  mental  feebleness.  Man  is  distinguished  from  the  brute  by 
his  self-control.  Let  him  bear  this  fact  in  mind  and  raise  him- 
self above  the  animals  by  a  determined  efTort  of  the  will. 
Pure  thoughts  and  chaste  associations,  vigorous  physical  exer- 
cise and  a  resolute  effort  to  act  a  manly  part  will  always  be 
successful. 

Traumatic  Nervous  Affectioxs  (Traumatic  ^'euroses 
AXD  Psychoses),  Spixal  Coxcussiox. 

The  present  tendency  of  neurology  is  to  deny  the  existence  of 
any  special  nervous  affection  produced  by  trauma  or  shock. 
There  may  follow  from  these  causes  • 

1.  Surgical  injuries. 

2.  Neurasthenic  states, 
o.  Hysterical  states. 

4.  Hemorrhagic,  inflammatory,  and  degenerative  diseases. 

5.  Combinations  of  the  foregoing. 

These  troubles  may  follow  not  only  railway  but  other  injuries, 
but  are  especially  liable  to  follow  those  associated  with  intense 
fright. 

2.  Traumatic  neurasthenia,  or  "traumatic  neurosis,*'  does  not 
differ  from  forms  of  neurasthenia  produced  by  other  causes,  ex- 
cept that  with  it  there  may  be  certain  sprains  and  surgical  trou- 
bles. Traumatic  neurasthenia  not  infrequently  is  associated 
with  much  spinal  pain,  and  in  women  especially  the  clinical 
symptom  group  known  as  "  spinal  irritation  ■' may  develop.  In 
other  cases  there  may  be  more  of  the  features  of  spinal  asthenia. 
When  to  these  spinal  symiDtoms  a  partial  paraplegia  is  added,  we 
have  the  disease  that  has  been  called  "  railway  spine,"  or  spinal 
concussion.  The  anatomical  names  given  to  this  used  to  be 
spinal  anaemia,  spinal  hypersemia,  and  spinal  meningitis.  But 
no  evidence  has  as  yet  proved  the  exact  nature  of  the  lesion. 

3.  Traumatic  hysteria  is  a  rare  affection  in  this  country.  It 
does  not  differ  from  hysteria  produced  by  other  causes,  except 
for  its  sudden  onset  and  occasional  h«urgical  complications.  It  is 
usually  a  hysteria  major  and  has  the  characteristic  stigmata  of 
that  type.  In  this  city  electrical  injuries  and  frights  have  pro- 
duced some  classical  cases  of  hysteria  major. 

4.  There  is  considerable  evidence  that  in  some  rare  cases  trau- 
matism may  produce  minute  multiple  hemorrhages  throughout 


NEURASTHENIA— NERVOUS   WOMEN.  4G1 

the  nervous  centres.  In  such  cases  there  are  usually  neuras- 
thenic or  hysterical  symiDtoms  and  in  addition  symptoms  of 
organic  disease. 

In  the  majority  of  cases  the  symptom  complex  is  something 
like  this  (Knapp) :  "  The  patient  has  headache  and  vertigo;  he  is 
depressed,  irritable,  and  hypochondriacal,  with  a  diminished 
power  of  application;  he  may  have  some  visual  disturbance,  he 
often  has  a  contracted  field  of  vision  and  occasionally  optic  atro- 
phy ;  there  is  some  tremor  and  perhaps  inco-ordination ;  he  has 
anaesthesia,  usually  not  limited  to  one-half  of  the  body,  and  with 
it  numbness  and  prickling ;  his  movements  are  slow  and  weak ; 
his  tendon  reflexes  are  exaggerated;  there  is  often  some  lack  of 
control  over  his  bladder;  and  he  may  have  pain  and  stiffness  in 
the  back  from  muscular  strain.*'  The  symptoms  eventually  re- 
semble a  disseminated  sclerosis. 

Massive  hemorrhages  and  serious  mechanical  injury  of  the 
nervous  centres  may  be  also  produced  by  injury. 

Finally,  it  is  a  well-known  fact  that  traumatisms  may  excite  in 
the  predisposed  locomotor  ataxia,  inebriety,  insanitj^,  or  may 
lead  to  the  development  of  a  cerebral  tumor. 

It  is  the  mental  impression,  the  shock,  much  more  than  the 
l^hysical  injury,  which  produces  the  neurosis  or  psychosis. 

The  symptoms  may  appear  soon  after  the  accident,  or  after  a 
period  of  relative  health  lasting  a  few  weeks  the  neurosis  grad- 
ually develops. 

The  most  important  practical  point  in  connection  with  the 
subject  is  the  diagnosis  and  the  elimination  of  malingering. 
This  is  additionally  difficult  for  the  reason  that  the  hopes  and 
anxieties  depending  upon  litigation  tend  to  cause  introspection, 
exaggeration  of  symptoms,  and  unconscious  bias  even  in  the  most 
honest.  The  opinion  among  American  neurologists  tends  to  favor 
the  seriousness  of  traumatic  neuroses.  While  malingering  is  not 
rare,  yet  if  the  patient  has  really  a  traumatic  neurasthenia  or 
hysteria  the  disease  may  not  be  a  trifling  one.  Careful  research, 
however,  often  tends  to  elicit  the  fact  that  previous  to  the  in- 
jury the  patient  was  an  alcoholic,  syphilitic,  or  neurotic,  and 
perhaps  had  already  the  beginnings  of  his  alleged  traumatic 
disorder.  In  no  part  of  clinical  medicine  is  a  careful  and 
searching  examination  and  weighing  of  symptoms  more  ur- 
gently called  for.  The  methods  of  carrying  out  such  examina- 
tions are  given  elsewhere.  Special  methods  for  testing  anaesthe- 
sia are  sometimes  needed.  The  two  sides  of  the  body  should  be 
tested  simultaneously  with  concealed  needles,  beginning  on  the 
trunk,  or  the  faradic  current  with  a  double-pointed  electrode 
may  be  used.  There  are  few  patients  who  can  successfully  de- 
ceive in  an  examination  covering  all  the  special  senses. 


462  DISEASES   OF  THE   NERVOUS   SYSTEM. 

The  treatment  of  the  traumatic  neuroses  calls  for  no  special 
notice. 

EXOPHTHALMIC   GOITRE   (BASEDOW^S   DISEASE, 
GRAVES^   DISEASE). 

Exophthalmic  goitre  is  a  chronic  neurasthenic  neurosis  cliar- 
acterized  by  rapid  heart  beat,  enlargement  of  the  thyroid  gland, 
protrusion  of  the  eyeballs,  and  various  neurasthenic  and  vaso- 
motor symptoms. 

JEtwlog I/.— The  disease  occurs  much  oftener  in  women  than 
men  (four  to  one).  It  is  a  disease  of  early  adult  life,  occurring 
chiefly  between  fifteen  and  thirty-five,  very  rarely  in  childhood, 
and  never  after  fifty.*  It  is  apparently  more  conunon  in  the 
Anglo-Saxon  race,  but  is  not  vei-y  frequent  in  America.  There 
is  very  rarely  any  direct  inheritance  of  the  disease,  but  the 
family  is  often  a  neuropathic  one.  As  a  rule,  the  patient  is  of  a 
neurotic  temperament.  Anaemia  and  debilitating  diseases  pro- 
mote its  development.  Goitre  and  heart  disease  do  not  seem  to 
predispose  to  it.  The  most  frequent  exciting  causes  are  power- 
ful depressing  emotions  and  severe  physical  exertion.  Rarer 
causes  are  injuries  and  infectious  diseases,  such  as  measles,  scarlet 
fever,  and  pneumonia. 

ISi/m2)toms.— The  disease  usually  begins  gradually  and  the 
first  symptom  is  in  most  cases  rapid  heart  beat  and  palpitations, 
accompanied  with  some  nervousness  and  tremor.  The  next 
symptom  is  enlai'gement  of  the  thyroid  gland,  and  at  about  the 
same  time  the  eyeballs  begin  to  protrude.  This  order  of  devel- 
opment does  not  always  take  place,  and  occasionally  one  of  the 
three  principal  symptoms  is  not  present.  The  disease  is  usually 
one  or  two  years  in  developing,  the  heart  symptoms  being  those 
which  continue  by  themselves  longest.  With  the  symptoms 
mentioned  there  occur  many  minor  troubles  which  are  more  or 
less  characteristic.  The  patient  is  usually  very  nervous  and  irri- 
table; a  distressing  insonniia  may  be  present.  There  is  almost 
uniformly  a  fine  tremoi-  (eight  to  nine  per  second)  of  the  hands, 
less  marked  in  the  lower  limbs  and  not  present  in  the  face  or 
tongue.  The  reflexes  are  exaggerated.  There  is  a  tendency 
at  times  in  walking  for  the  knees  suddenly  to  give  way.  I'he 
patient  rarely  has  neuralgias,  but  does  have  burning  or  fever- 
ish sensations  and  headaches.  The  skin  is  rather  reddened  and 
the  patient  sweats  profusely.  Pigmentation  and  vitiligo  are 
sometimes  seen,  and  urticaria  may  develop.     The  electrical  re- 

*  Among:  Sa  cases  at  N.  Y.  Post  Graduate  Clinic  (Fiske-Bryson)  there  were  8 
males,  25  females.  Apes:  thirteen  to  twenty,  8;  twenty-one  to  thirty,  8;  thirty-one  to 
forty,  6;  forty-one  to  fifty,  5;  fifty-one  to  sixty,  1. 


EXOPHTHALMIC   OOJTRE.  403 

HlHtancAi  of  th*>  body  Ik  much  dijninihh^^],  httirig  W>  U)  l,r>fXj  oIjjjih 
■inHU'.iu\  of  2,fm  to  :j,(XX).  Thara  In  muntUuu,^  a  derii'jot<rai>l)io 
hkiri,  a«  in  other  uinxruhthamc  ntaUiH.  Tlui  rcHpiratory  furjctjon 
ii*  weakenr^ci  and  chent  exparjHion  oft<ifi  faJJH  below'  one  inch 
(Fi«ke-I3ry»r>n;.  Atta/;kJ^  of  a  perHiKtr^nt  watery  diarrhoea  <xjeur. 
Ana.-mia  iw  usually  pref^.-nt.  There  j«  oeeaKionaily  polyuria,  i/iore 
rarely  {<lycoKurJa.  The  Juniih*.tH  are-  Irr'nrnlur  and  aiuerjorrhoja 
often  exlntH.     A  Blight  riwi  in  t^^njperature  may  oc<;ur, 

Tlie  raojor  HymoU>mH  of  the  diw^jane  are: 

Ta^ihyeardui  and  pulsating  arUiriea. 

(ioitre. 

ExopljtijalnjuB. 

Tremor. 

The  minor  HyrtLpUymx  iwft : 

NervouBneHH. 

Sweating, 

Infsfjmnia. 

JjdHi-^.iKid  electrical  reBiKtance, 

UiminiBhe^J  renpiratory  expannion, 

HubjacAAvft  BenfeationB  of  heat. 

J^iarrhoia. 

Polyuria, 

Hyrapt/yffvH  in  haUiil. — Ta/Rhycardia  i«  the  most  constant  hingle 
hymptrjin.  The  pulw^s  beats  from  IW  to  120  per  minute  UHually, 
but  may  rise  to  W)  or  even  2^XJ.  its  rhythm  is  usually  steady; 
but  palpitations  r>ccur  easily,  even  without  exciting  cause.  TIjc 
patient  may  wake  up  at  night  with  distressing  attacks,  some- 
thing like  thowi  of  angina  i>e<;toris,  but  the  intenw^  pain  and 
Benwe  of  impending  death  are  usually  abw:!nt.  'J'he  ijeart  is  di- 
Iate<^l  and  a  Bystrjiic  njurmur  is  oftf^n  heard  at  the  baw^  propagate<l 
along  the  arteries.  Itf^al  organic  disease,  however,  is  rare.  The 
arteries  are  dilate^l  and  soft.  They  pulsate  strongly,  particularly 
the  carotids.  A  thrill  is  sfjmetimes  felt  over  the  heart  and  al- 
ways over  the  goitre.     The  ixTtarUx.]  tfiJUiUjn  is  nonnal  or  low. 

The  thyroid  gland  ij«  usually  iiu\ixrmn\  symmetrically;  later  in 
the  diwiase  the  isthmus  is  affe/^ted  and  the  three  lobes  r>f  the 
gland  stand  out  prominently  (Tig.  ]Iy8j.  Jf  only  part  of  the  gland 
is  involved  it  is  oftenest  the  right  lobe.  A  thrill  is  felt  over  it 
and  a  systolic  murmur  f^an  Ix:;  heard. 

The  bulging  of  the  eyes  or  exophthalmus  is  usually  bilateral 
and  even.  If  one  eye  is  alone  or  more  affect^^d  it  is  the  right. 
The  exophthalmuB  varies  much  in  degree.  It  is  not  usually  very 
great,  but  may  l>e  so  exc^sive  as  to  prevent  closing  of  the  lid« 
and  to  expose*  the  insertions  of  the  rer^ti.  The  eyeljall  may  V>e 
slightly  enlarged  Tone-tenth).  The  pupils  are  nonual  and  vision 
lij  not  impaired,  though  myopia  rx?ca.siorially  occurs.     The  fundus 


i64 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


and  visual  field  are  normal.  Paralysis  of  some  of  the  eye  muscles 
is  a  rare  complication.  Weakness  of  the  internal  recti '  and  ex- 
ophoria  are  frequent.  The  lids  show  certain  peculiarities.  One 
of  these,  known  as  Von  Graefe's  symptom,  consists  in  the  in- 
ability of  the  lid  to  follow  the  downward  movement  of  the  eye- 
ball. When  the  patient  is  told  to  follow  the  movement  of  the 
finger  vertically  downward  the  eyeball  moves  steadily,  but  the 
lid  catches,  as  it  were,  and  refuses  to  follow  or  does  so  in  a  jerky 
manner.  Another  symptom,  known  as  /Stellwag's  symptom,  is  a 
considerable  retraction  of  the  lids,  especially  the  upper  one.  Both 
this  and  Yon  Graefe's  symptom  are  due  to  a  common  tendency 


Fig.  198.— ExoPHTHALj 


HE,  WITH  AND  WITHOUT   EXOPHTHALMUS. 


of  the  lids  to  retract — due  perhaps  to  overaction  of  the  muscle  of 
Miiller.     A  tremor  of  the  lids  sometimes  occurs. 

Course.— The  disease  progresses  slowly.  After  a  year  or  two 
it  often  becomes  stationary  for  a  long  time.  Cases  of  gradual 
spontaneous  recovery  occur.  The  natural  duration  of  most  re- 
coverable cases  is  two  to  four  years.  In  those  which  do  not  re- 
cover the  disease  lasts  five,  ten,  or  more  years.  Eventually  the 
patient  emaciates,  the  heart  becomes  weaker,  albuminuria  and 
dropsy  appear,  diarrhoea  sets  in,  and  the  patient  dies  of  exhaus- 
tion or  is  carried  off  by  phthisis  or  some  intercurrent  disease. 
Other  cases  having  improved  up  to  a  certain  point  remain  in 
this  state  for  years. 

Complications. — Mental  derangement  occasionally  occurs  in 
the  later  stages  of  the  disease.     Hysterical  crises,  epileptic  at- 


EXOPHTHALMIC   GOITRE.  465 

tacks,  choreic  movements,  paralysis  of  the  ocular  muscles,  mus- 
cular a,trophy,  paralysis  agitans,  Addison's  disease,  diabetes,  loco- 
motor ataxia,  and  local  oedema  have  all  been  observed.  With 
the  exception  of  hysterical  attacks  these  complications  are  rare. 

Abort ive  Forms.— TYii^  name  is  applied  to  cases  in  which  only 
a  part  of  the  distinctive  symptoms  develop.  Tachycardia  al- 
ways exists ;  with  it  are  tremor  and  moist  skin,  lessened  electrical 
resistance  and  nervousness.  Or  tachycardia  and  goitre  may  alone 
be  present. 

Fathology.— The  disease  may  be  regarded  as  a  neurasthenic  or 
atonic  condition  of  the  vasomotor  centres  and  of  the  great  vis- 
ceral nerves,  the  vagus  and  spinal  accessory.  As  a  result  of  the 
first  condition  the  blood-vessel  walls  are  relaxed  and  the  cutane- 
ous hyperaemia  results.  The  enlargement  of  the  thyroid  is  ex- 
plained by  a  vasomotor  paresis  of  its  vessels.  It  is  a  kind  of 
erection  of  the  organ.  The  exophthalmus  is  also  due  chiefly  to 
paralysis  of  the  orbital  vessels.  A  tonic  spasm  of  the  muscle  of 
Miiller  is  thought  to  help  in  producing  this  symptom.  This 
muscle  consists  of  unstriated  fibres  originating  in  the  membranous 
lining  of  the  orbit  and  inserted  into  the  lids.  It  is  rudimentary 
in  man,  and  its  influence  in  causing  protrusion  of  the  globe  nmst 
be  very  small.  The  deposit  of  retrobulbar  fat  is  a  secondary 
phenomena.  The  rapid  heart  beat  is  probably  due  to  impair- 
ment of  the  inhibitory  fibres  of  the  spinal  accessory.  Thus  all 
the  symptoms  may  be  explained  on  the  theory  of  a  vasomotor 
and  cardio-inhibitory  paresis. 

Another  theory  suggested  of  late  is  that  the  disease  is  primar- 
ily an  affection  of  the  thyroid  gland ;  that  this  organ  is  overactive 
and  throws  into  the  blood  substances  that  irritate  the  nerves. 
More  properly  the  mechanism  should  be  that  it  withdraws  from 
the  blood  too  much  of  those  substances  which  are  needed  for 
nerve  nutrition.  The  principal  substance  so  far  as  known  which 
develops  in  excess  when  the  thyroid  fails  to  act  is  mucin.  In 
myxoedema  the  thyroid  giand  atrophies,  and  a  long  list  of  symp- 
toms almost  directly  the  opposite  of  those  of  exophthalmic  goitre 
occurs.  The  thyroid  theory  is  weakened  by  the  fact  that  tachy- 
cardia and  many  other  characteristic  symptoms  may  develop 
without  a  goitre,  and  that  in  simple  enlargement  of  the  thyroid 
the  symptoms  of  Graves'  disease  do  not  appear. 

Small  hemorrhages  and  congestion  of  the  medulla  have  been 
found  in  a  few  cases.  Aside  from  this,  no  important  changes  in 
the  central  nervous  system  have  been  discovered.  The  heart  is 
dilated  and  enlarged,  endocarditis  is  sometimes  present,  oftener 
not.  The  arteries  are  dilated.  The  thyroid  gland  is  vascular 
and  its  arteries  dilated;  its  proper  structure  is  increased  in 
amount.  There  is  increase  of  fat  and  vascular  dilatation  in 
30 


466  DISEASES   OF  THE  NERVOUS   SYSTEM. 

orbit.  The  thymus  gland  is  usually  present  to  a  greater  extent 
than  normal. 

Prognosis.— Aho\xt  one-fifth  of  the  cases  get  well  or  practically 
well.  Probably  over  half  the  cases,  if  they  can  be  properly 
treated,  reach  a  fairly  comfortable  condition  of  improvement. 
The  cases  in  which  symj^toms  come  on  quickly  have  the  most 
favorable  prognosis.  In  those  with  marked  exophthalmus  and 
goitre  the  prognosis  is  not  so  good. 

Diagnosis.— The  disease  can  be  distinguished  by  the  persist- 
ent tachycardia,  with  goitre  or  exophthalmus,  and  in  its  early 
stage  by  the  tachycardia  Avith  tremor,  moist  skin,  sensations  of 
heat,  nervousness,  insomnia,  lessened  respiratory  expansion,  and 
electrical  resistance.  A  symptomatic  Graves'  disease  may  some- 
times be  caused  by  a  goitre  pressing  on  the  vagus  or  sympathetic 
and  causing  irregular  heart  beat  and  perhaps  exophthalmus.  In 
these  cases  the  history  of  a  long-standing  goitre  exists,  the  heart's 
action  is  irregular,  the  exophthalmus  is  usually  partial  and  one- 
sided. In  abortive  forms  it  is  necessary  to  have  tachycardia  and 
at  least  one  other  of  the  four  major  symptoms  to  make  a  diag- 
nosis. 

Treatment. — Rest  is  the  most  important  single  thing.  The 
patient  should  be  put  to  bed  or  kept  on  the  back  for  one  or  more 
months.  Freedom  from  excitement  and  worry  must  be  en- 
joined. No  especial  diet  is  needed,  nor  do  climatic  influences 
or  baths  or  mineral  waters  have  much  effect.  Some  cases  are 
said  to  be  improved,  however,  by  removal  to  heights  of  one  to 
three  thousand  feet.  In  most  cases  a.  sea-voyage  is  the  better 
change  if  one  is  made. 

The  drugs  used  are  numerous.  The  most  efficient  are  tincture 
of  strophanthus  in  doses  of  fifteen  to  forty  drops  daily,  iodide  of 
potassium  or  the  syrup  of  hydriodic  acid,  arsenic  and  bromide  of 
potassium  used  together ;  quinine,  mineral  acids,  and  iron,  used 
together.  Other  remedies  are  tincture  of  aconite  in  ni  v.  or  aco- 
nitia  gr.  ^h^  doses,  tincture  of  belladonna  increased  to  the  limit 
of  tolerance,  tincture  of  cactus  grandiflorus  in  tt^  x.  to  xx.  and 
tincture  of  veratrum  viride,  tti  x.  to  xxx.  dose,  and  the  picrate  of 
ammonia,  gr.  i.  to  ij.  t.  i.  d.  Of  these  drugs,  strophanthus,  the 
iodides,  bromides,  and  iron  have  served  me  best.  Digitalis  is  of 
doubtful  value. 

Electricity  possesses  some  utility.  It  should  be  given,  if  possi- 
ble, two  or  three  times  daily  in  the  form  of  galvanism  and  in 
doses  of  two  to  six  milliamperes  for  ten  minutes.  The  technique 
is  as  follows.  Positive  pole  on  back  of  neck,  negative  drawn 
along  course  of  vagi  in  the  neck ;  each  side  two  minutes.  Same 
with  positive  pole  placed  subaurally  one  minute;  negative  pole 
over  thyroid  two  minutes,  negative  over  cardiac  region  one  min- 


EXOPHTHALMIC  GOITRE.  467 

ute,  positive  pole  over  eyes,  negative  over  thyroid  one  minute, 
two  milliamperes.  The  faradic  current  may  be  used  for  general 
tonic  effects  or  combined  locally  with  the  galvanic.  The  patient 
should  lie  down  during  treatment  and  remain  quiet  for  an  hour 
later. 

For  the  palpitations,  sulphate  of  sparteine  or  strophanthus 
with  Hoffmann's  anodyne  may  be  used.  The  ice-bag  placed  over 
the  heart  and  neck  is  helpful  and  may  be  used  systematically. 
Tonic  hydrotherapy  is  often  useful,  but  should  be  carefully  em- 
ployed. Surgical  treatment  until  late  years  has  been  unsuccess- 
ful. Recently  several  cases  have  been  reported  in  which  cure 
has  been  produced  by  partial  removal  of  the  thyroid  gland.  This 
measure  is  yet  in  an  experimental  stage.  Treatment  of  the  nose 
has  been  said  to  cause  disappearance  of  symptoms,  but  its  utility 
is  very  doubtful.  Respiratory  exercises  by  which  the  patient  is 
taught  to  increase  his  chest  expansion  do  much  good,  as  shown 
by  Dr.  Bryson. 

Mild  compression  of  the  lids  at  night  seems  to  help  the  ex- 
ophthalmus,  and  slight  and  steady  compression  of  the  thyroid 
gland  sometimes  reduces  its  size  a  little. 


CHAPTER  XXV. 

PROFESSIONAL  NEUROSES,  OCCUPATION  NEUROSES 
(WRITERS^  CRAMP  AND  ALLIED  AFFECTIONS.) 

Writers'  cramp  is  a  chronic  functional  neurosis  character- 
ized by  spasmodic,  tremulous,  inco-ordinate  or  paralytic  disturb- 
ance when  the  act  of  writing  is  attempted,  and  associated  with 
feelings  of  fatigue  and  pain. 

Etiology. — It  is  a  disease  of  the  present  century,  and  has  been 
particularly  noted  since  the  introduction  of  steel  pens  about  the 
year  1820.  A  neuropathic  constitution  is  often  present,  and  some- 
times there  is  a  hereditary  history.  Men  are  much  more  subject 
to  the  disease  than  women.  'The  most  susceptible  age  is  between 
twenty-five  and  forty.  It  rarely  occurs  after  fifty  or  before 
twenty.  Clerks  and  professional  writers  are  naturally  much 
more  subject  to  the  disease.  Excessive  worry,  intemperance, 
and  all  debilitating  influences  predispose  to  it.  The  chief  excit- 
ing cause  is  excessive  writing.  But  this  is  not  all.  The  writing 
that  is  done  under  strain  or  a  desire  to  finish  a  set  task  is  the 
harmful  thing.  The  style  of  writing  is  also  an  important  factor. 
Writing  done  in  a  cramped  posture  Avith  movements  of  the  finger 
alone  or  with  the  little  finger  or  wrist  resting  on  the  table  is 
most' injurious.  Free-handwriting  done  from  the  shoulder  ac- 
cording to  the  American  system  is  least  harmful.  Shaded  or 
heavy  Avriting  wdth  sharp  steel  pens  is  also  productive  of  harm. 
Copying  is  much  more  harmful  than  composing.  x\uthors  seldom 
have  writers'  cramp.  Albuminuria,  lead-poisoning,  exposure  to 
wet  and  cold,  and  local  injuries  are  sometimes  exciting  causes. 

SymXJtoms.—S^viiex^'  cramp  very  rarely  attacks  a  person  sud- 
denly. The  patient  first  notices  a  certain  amount  of  stiffness  oc- 
curring at  times  in  the  fingers,  or  the  pen  is  carried  with  some 
uncertainty  and  jerky  movements  are  made.  He  feels  a  sensa- 
tion of  fatigue  in  the  hand  and  arih,  and  this  may  amount  to  an 
actual  tired  pain.  The  first  symptoms  may  last  for  months  or 
even  years.  The  hand  is  rested  as  much  as  possible,  new  pens  or 
penholders  and  new  modes  of  holding  it  are  tried.  Often  the 
patient,  fearing  the  onset  of  the  cramp,  and  as  its  result  loss  of 
employment,  becomes  anxious,  worried,  and  mentally  depressed. 


PROFESSIONAL  NEUROSES,  OCCUPATION  Js^EUROSES.      469 

Sometimes  the  trouble  is  worse  when  beginning  a  daily  task,  and 
it  gradually  wears  off  in  a  few  hours.  At  other  times  exactly  the 
reverse  is  the  case.  When  the  disease  has  reached  its  highest 
stage,  writing  becomes  almost  or  entirely  impossible.  The  mo- 
ment the  pen  is  taken  in  the  hand  and  an  attempt  at  using  it 
made,  spasmodic  contractions  of  some  of  the  fingers,  or  even  of 
the  arm,  occur,  the  pen  flies  in  any  direction,  and  it  is  impossible 
to  control  or  co-ordinate  the  movements.  The  rule  is  that  al- 
though writing  cannot  be  done,  all  other  complex  movements 
are  performed  as  well  as  ever.  Thus  the  sufferer  from  writers' 
cramp  may  be  able  to  play  the  piano,  or  paint,  or  thread  a  needle, 
or  use  the  hand  in  any  complex  movements.  This  limitation, 
however,  is  not  always  present.  Telegraphers,  who  use  to  some 
extent  the  same  muscles  as  in  writing,  and  who  also  often  have 
to  do  a  great  deal  of  writing,  are  liable  to  suffer  from  both 
writers'  and  telegraphers'  cramp  at  the  same  time.  No  evidences 
of  actual  paralysis  are  present  in  the  affected  muscles,  and  there 
is  rarely  aniesthesia,  but  the  arm  aches  and  is  sometimes  tender. 
Sensations  of  numbness  and  prickling  are  present :  in  rare  cases 
vasomotor  disturbances  are  observed ;  associated  nmscular  move- 
ments of  the  other  arm  or  of  the  neck  or  face  sometimes  occur. 
The  hand  may  tremble  on  attempting  to  write  or  fall  almost 
paralyzed  when  the  pen  is  taken. 

Tlie  various  symptoms  occur  with  different  degrees  of  promi- 
nence, so  that  the  disease  has  been  classed  under  the  heads  of  (1) 
the  spastic,  (2)  the  neuralgic  or  sensory,  (8)  the  tremulous,  and  (4) 
the  paralytic  forms.  These  forms  are,  however,  often  more  or 
less  mixed. 

1.  The  spastic  form  is  undoubtedly  the  most  common,  and  it 
has  given  to  the  disease  its  name.  Cramp  of  some  nmscle  or 
muscles  is  present  in  over  half  of  the  cases.  The  muscles  of  the 
thumb  and  first  three  fingers  are  of  tenest  affected,  and  in  some 
cases  the  flexors,  in  some  the  extensors,  are  chiefly  involved.  In 
telegraphers'  cramp  it  is  the  extensors,  but  in  writers'  cramp  the 
flexors,  that  are  mainly  attacked.  The  thumb  or  forefinger  or 
the  little  finger  alone  may  suffer  from  the  spasms.  The  prona- 
tors and  supinators  are  quite  often  involved.  The  spasm  is  usu- 
ally a  tonic  one.  With  the  spasm  there  is  also  inco-ordination 
so  far  as  writing  movements  are  concerned,  and  this  fact  is  quite 
as  important  in  producing  the  bad  writing  as  the  spasm.  The 
inco-ordination  is  apparently  of  the  motor  type,  and  is  not  due 
to  anaesthesia  of  the  muscle  sense,  as  in  locomotor  ataxia. 

2.  The  neuralgic  form  resembles  the  spastic  plus  sensations  of 
fatigue  and  pain,  which  are  quite  severe  and  are  brought  on  by 
writing.     There  may  be  tenderness  along  the  arm  also. 

3.  The  tremulous  type,  though  rare,  is  very  characteristic 


470  DISEASES  OF  THE  NERVOUS   SYSTEM. 

when  present.  The  patient  when  attempting  to  write  observes 
a  tremulous  movement  of  his  hand  and  arm.  This  ceases  when 
his  attempts  to  write  cease.  The  tremor  usually  affects  most 
the  fingers  used  in  pen-prehension,  but  it  also  spreads  to  the 
forearm  and  may  even  involve  the  entire  extremity.  An  oscilla- 
tory or  lateral  tremor,  due  to  involvement  of  the  pronators  and 
supinators,  has  been  observed.  The  tremor  is  of  the  character 
known  as  "  intention-tremor,*'  such  as  is  observed  in  disseminated 
sclerosis.  It  is  shorter  in  range  and  more  rapid  than  the  tremor 
of  that  disease. 

4.  The  paralytic  form,  or  that  type  in  which  muscular  feeble- 
ness is  the  dominant  symptom,  is  said  to  be  rare  by  Gowers,  and 
this  accords  with  my  experience.  German  writers  speak  of  it  as 
common.  In  the  typical  paralytic  form  the  patient,  as  soon  as 
he  begins  to  write,  feels  an  overpowering  sense  of  weakness  and 
fatigue  in  the  fingers  and  arm.  The  fingers  themselves  loosen 
their  grip  and  the  i^en  may  drop  from  the  hand.  Powerful  im- 
pulses of  the  will  and  change  in  the  mode  of  holding  the  pen 
enable  the  sufferer  to  continue,  but  the  arm  aches  and  finally  is 
absolutely  painful,  and  weakness  and  fatigue  compel  the  writer 
to  desist.  Sometimes  the  paretic  condition  is  succeeded  by  the 
spastic.  Many  of  the  cases 'of  paralytic  writers'  cramp  are  not 
true  examples  of  the  neurosis,  but  are  rather  cases  of  neuritis  of 
a  rheumatic  or  other  type. 

General  Sy)nptoms. — Writers'  cramp  is  essentially  a  motor 
neurosis,  and  its  leading  symptom  is  the  impairment  of  a  motor 
function.  Other  symptoms,  however,  both  general  and  local,  are 
always  associated  with  it.  These  are  ma^inly  (1)  psychical  and  (2) 
sensory,  more  rarely  (3)  vasomotor  and  (4)  trophic. 

1.  Psychical  symptoms.  The  patient  is  often  nervous,  emo- 
tional, and  mentally  depressed  at  times.  He  suffers  from  in- 
somnia and  vertigo.  Patients  are  generally  unwilling  to  admit 
that  there  is  any  other  trouble  than  the  local  one,  and  only  care- 
ful exammation  may  bring  evidence  of  constitutional  trouble. 
There  are  cases  of  purely  mental  writers'  cramp. 

2.  Sensory  troubles.  These  consist  of  pain,  sense  of  fatigue, 
feelings  of  numbness,  prickling,  pressure,  weight,  tension,  con- 
striction, etc.  Hypersesthesia,  and  more  rarely  anaesthesia,  are 
also  observed.  The  most  common  sensory  symptom  is  that  of 
aching  and  fatigue,  and  this  is  usually  confined  to  the  arm, 
and  oftenest  runs  along  the  course  of  the  radial  and  median 
nerves.  The  cervical  vertebrae  may  be  tender,  and  sometimes  pa- 
tients have  a  headache  in  the  parietal  region  of  the  side  opposite 
the  affected  arm. 

3.  Vasomotor,  trophic,  and  secretory  disturbances.  The  con- 
dition known  as  digiti  mortui  has  been  observed,  coming  on  par- 


PROFESSIONAL  NEUROSES,  OCCUPATION  NEUROSES.      471 

oxysmally.  It  is  a  symptom  which  the  general  neurasthenic  state 
helps  to  produce.  When  the  nerves  are  involved  decided  vascu- 
lar changes  may  occur,  such  as  passive  congestion  of  the  hand 
and  arm,  with  swelling  and  turgescence  of  the  fingers,  and  a 
sensation  of  throbbing.  In  bad  cases  the  fingers  will  look  as  if 
they  had  chilblains.  Local  sweating,  dryness  of  the  skin,  and 
cracking  of  the  nails,  all  are  conditions  which  may  follow  impair- 
ment of  writing  power  from  neuritic  causes. 

Electrical  Reactions.— The  results  of  observations  upon  the 
electrical  reactions  of  the  affected  parts  are  somewhat  contradic- 
tory. Ordinary  tests  will,  as  a  rule,  reveal  very  little  change. 
Sometimes  there  is  a  quantitative  increase,  sometimes  a  decrease, 
of  irritability  to  both  forms  of  current.  The  increase  occurs  in 
the  earlier  stages,  the  decrease  in  the  later.  An  increase  or 
modification  of  electro-muscular  sensibility  has  been  noted. 
The  electrical  examinations,  therefore,  are  only  of  value  in  ex- 
cluding a  neuritis  or  possibly  in  determining  the  stage  of  the 
disease. 

Pathology. — Neuritis  is  undoubtedly  present  in  some  forms  of 
writers'  cramp,  so  called.  It  is  not  present,  however,  so  far  as 
external  tests  go,  in  the  typical  neurosis.  Nor  are  there  any 
post-mortem  observations  throwing  light  on  the  anatomy  of  the 
disease.  We  must  believe,  therefore,  that  it  is  a  neurosis  having 
no  appreciable  anatomical  basis. 

The  act  of  writing  is  a  very  complicated  one,  calling  into  play 
numerous  sets  of  delicately  innervated  muscles.  These  muscles 
are  employed:  1,  in  pen-prehension;  2,  in  pen  movement;  3,  in 
holding  the  arm  and  wrist  tense. 

1.  The  muscles  employed  in  pen-prehension  are  the  two  outer 
•lumbricales,  two  outer  interossei,  the  adductor  muscles  of  the 
thumb,  the  flexor  longus  pollicis;  to  some  extent  the  deep  and 
superficial,  short  and  long  flexors,  and  the  extensors  of  the  thumb. 
These  are  supplied  mostly  by  the  ulnar  (interossei,  adductor  pol- 
licis, inner  heads  of  deep  flexor  of  fingers,  and  inner  head  of  short 
fiexor  of  thumb).  The  rest  of  the  muscles  are  supplied  by  the 
median. 

2.  In  moving  the  pen,  if  the  writing  is  done  mainly  by  finger 
and  not  by  arm  movements,  the  muscles  brought  into  play  are 
the  flexor*  longus  pollicis,  extensor  secundi  internodii  poUicis, 
flexor  profundus  digitorum,  extensor  communis  digitorum,  and 
to  some  extent  the  interossei.  The  musculo-spiral  and  ulnar 
nerves  innervate  these  groups  about  equally.  In  moving  the 
pen  by  the  "American''  or  free-hand  method  there  is  a  very 
slight  play  of  the  above  muscles,  while  most  of  the  pen  move- 
ment is  done  by  the  muscles  of  the  upper  arm  and  shoulder,  viz., 
the  teres  major,  pectorales,  latissimus  dorsi,  biceps,  and  triceps. 


472  DISEASES  OF  THE  NERVOUS   SYSTEM. 

The  spinal  centres  for  these  muscles  are  distributed  along  the 
fifth,  sixth,  and  seventh  cervical  segments  of  the  cord.  The  cells 
are  larger  and  situated  more  superficially  in  the  anterior  gray 
horns. 

3.  Besides  these  movements  involved  in  pen-i^rehension  and 
in  the  letter-making,  a  certain  amount  of  muscular  tension  is  ex- 
ercised in  "  poising "  the  forearm  and  hand  and  steadying  the 
wrist.  The  biceps  and  triceps,  the  supinators  and  the  fiexors, 
and  extensors  of  the  hand  are  here  brought  into  i^lay. 

From  the  foregoing  it  will  be  seen  that  the  muscles  of  pen- 
prehension  are  most  used  in  all  but  the  free-hand  style  of  writ- 
ing, since  the  same  groups  have  a  double  duty,  that  of  clasping 
and  of  moving  the  instrument. 

While  writers'  cramp  is  often  complicated  with  some  neurotic 
disturbance  leading  to  associated  symptoms  of  pain,  paralysis, 
tenderness  over  nerves,  vasomotor  disturbances,  etc.,  there  can 
be  no  doubt  that  the  lesion  in  typical  cases  is  central.  Writing 
is  an  acquired  automatic  movement,  and  it  must  have  as  its  ana- 
tomical basis  a  certain  established  arrangement  of  nerve-Cell 
groups  in  the  cervical  part  of  the  spinal  cord.  The  nerve  im- 
IDulses  generated  in  the  cerebral  cortex  pass  along  the  pyramidal 
tracts  and  set  at  work  those  ganglion  groups  which,  in  turn,  in- 
nervate the  muscles  used  in  writing  with  motor  impulses.  These 
grovips  are  themselves  innervated  also  sensorially  by  the  nerves 
of  muscle  sense  in  movement.  In  writers'  cramp  tho  spinal 
groups  of  cells  are  more  or  less  used  up  or  exhausted,  and  the 
motor  impulse  which  naturally  would  innervate  them  strikes 
cells  which  respond  unequally,  or  it  overflows  to  other  cell  groups, 
and  hence  the  spasmodic,  irregular  movements  of  the  arm. 
The  cerebral  centres  in  the  cortex  or  basal  ganglia  are  closely 
connected  with  those  in  the -cord,  and  may  be  said  to  form  part 
of  the  writing  mechanism.  It  happens  in  some  cases  that  this 
centre  too  is  exhausted  and  discharges  its  impulses  irregularly. 
In  some  cases,  therefore,  the  cerebral,  and  in  some  the  spinal, 
cell  groups  are  the  more  affected,  and  a  diagnosis  of  the  exact 
condition  in  each  is  approximately  possible  and  may  be  not 
without  practical  importance.  Writers'  cramp  is  a  disorder  of 
efferent  paths  and  stations.  The  muscular  sense  does  not  seem 
to  be  involved. 

The  pathology  of  writers'  cramp  is  that  of  all  the  other  forms 
of  occupation  neuroses,  and  nothing  need  be  said  upon  this 
point  regarding  them  when  they  come  to  be  considered. 

The  diagnosis  of  well-marked  cases  of  writers'  cramp  presents 
no  difficulty.  In  the  earlier  stages,  however,  it  may  be  confounded 
with  a  large  number  of  disorders,  viz.,  post-hemiplegic  chorea, 
hemiataxia,  progressive  muscular  atrophy,  progressive  locomotor 


PROFESSIONAL  NEUROSES,  OCCUPATION  NEUROSES.      473 

ataxia,    various    forms    of    tremor,   lead    paralysis,    rheumatoid 
arthritis,  neuritis,  cerebral  and  nerve  tumors,  and  tenosynovitis. 

In  many  of  these  cases  it  is  only  necessary  to  bear  in  mind  the 
history  of  the  disease  in  order  at  once  to  reach  a  safe  conclusion 
as  to  its  nature. 

If  there  is  a  great  deal  of  pain  in  the  arm,  with  tenderness 
along  the  course  of  the  nerves;  if  thei-e  is  decided  change  in  the 
electrical  reactions ;  if  there  are  sensations  of  tingling,  numbness 
etc. ;  and  if  the  patient  shows  an  absolute  loss  of  power  in  the 
various  groups  of  muscles,  with  some  incapacity  for  doing  other 
acts  besides  the  one  with  which  he  is  specially  concerned,  then 
the  trouble  is  undoubtedly  peripheral  and  due  largely  to  an  un- 
derlying neuritis.  The  prognosis  in  these  cases  is  much  more 
favorable.  If,  on  the  other  hand,  the  disorder  comes  on  in  per- 
sons who  have  done  an  excessive  amount  of  writing;  if  it  is 
associated  with  nerve  strain;  if  the  electrical  reactions  are  but 
slightly  changed,  the  sensory  symptoms  slight,  and  the  motor 
inco-ordination  marked,  limited  to  the  special  class  of  work,  and 
not  accompanied  with  absolute  paresis,  the  disorder  is  central 
and  needs  both  a  different  treatment  and  prognosis.  It  is  these 
cases  that  form  writers'  cramp  proper,  although  no  doubt  neuritic 
and  central  forms  are  associated,  or  the  former  may  run  into  the 
latter. 

Course  and  Duration. — Writers'  cramp  is  a  chronic  disease. 
It  begins  insidiously  and  attacks  one  group  of  muscles  after  an- 
other as  each  is  brought  into  play  by  new  methods  of  writing. 
If  the  left  hand  is  used,  that,  too,  is  liable  to  become  affected. 
The  course  varies,  however ;  for  a  time  progress  may  be  arrested 
or  improvement  set  in.  When  the  disease  becomes  well  estab- 
lished it  will  most  often  last  a  lifetime. 

Prognosis. — The  prognosis  is  unfavorable,  yet  not  so  much  so 
as  has  once  been  thought.  Undoubted  cases  of  complete  recov- 
ery have  been  reported,  even  under  unfavorable  conditions. 

The  prognosis  is  much  more  favorable  if  the  patient  begins 
treatment  early  and  before  marked  spastic  symptoms  are  present. 
It  is  more  favorable  in  the  neuralgic  forms.  Some  patients  who 
suffer  from  a  mild  form  of  the  trouble  manage,  by  the  help  of  in- 
struments or  special  pens,  to  do  their  work  for  years.  The  more 
acute  the  disease  and  the  more  evidently  peripheral  and  neuritic 
its  origin,  the  better  the  prognosis.  In  over  one-fourth  of  the 
cases,  patients  who  use  their  sound  arm  will  not  be  affected  in  it. 

The  facts  stated  regarding  the  cause,  physiology,  and  general 
symptomatology  of  writers'  cramp  apply  to  the  other  torms  ot 
occupation  neuroses.  A  few  special  details,  however  will  be 
given  regarding  these.  The  most  common  and  important  are 
musicians'  cramp  and  telegraphers'  cramp. 


474  DISEASES  OF  THE  NERVOUS   SYSTEM. 

Musicians'  Cra  mjj.— Vndev  this  head  we  mclude  pianists' 
cramp,  viohnists''  cramp,  flutists'  cramp,  and  the  cramp  of  clar- 
ionet players. 

Pianists''  cramp  occurs  usually  in  young  women  who  are 
studying  to  become  professionals  or  who  are  especially  hard- 
working and  ambitious.  The  absurd  "  Stuttgart  method ''  of 
teaching  the  piano,  in  which  the  motions  are  confined  as  much 
as  possible  to  the  fingers,  predisposes  especially  to  this  disease. 
The  symptoms  are  those  of  fatigue,  pain,  and  weakness.  The 
pains  are  of  an  aching  character.  They  are  felt  in  the  forearm 
especially,  but  extend  up  the  arm  and  between  the  shoulders. 
Sl3asmodic  symptoms  are  rare.  The  right  hand  is  of tener  affected, 
but  both  hands  eventually  become  involved. 

Violinists'  cramp  may  attack  the  right  hand  which  holds  tha 
bow  or  the  left  hand  which  fingers  the  strings,  but  more  often 
the  left  hand  is  affected. 

Clarionet  players  sometimes  suffer  from  cramp  of  the  tongue 
and  of  the  laryngeal  muscles. 

Flute  players  suffer  not  very  infrequently  from  slight  laryn- 
geal spasms.  A  similar  trouble  affects  elocutionists.  The  term 
mogophonia  is  applied  to  this  type. 

Telegraphers'  cramp  affects  especially  those  operators  using 
the  Morse  system,  an  instrument  which  is  still  the  one  most 
widely  in  vogue.  Contrary  to  the  opinions  of  previous  writers, 
Dr.  Lewis  believes  that  this  neurosis  is  not  a  rare  one  and  is 
destined  to  become  more  frequent.  In  this  city  the  cramp  is 
not  rare,  the  proportion  being  about  one  in  every  two  hundred. 
The  technical  name  among  operators  for  the  cramp  is  "loss 
of  the  grip."  In  telegraphing,  the  extensors  of  the  wrist  and 
fingers  are  called  most  into  play,  and  hence  are  most  and  earli- 
est affected.  The  symptoms  come  on  very  slowly,  the  thumb 
and  index-finger  being  fij-st  affected.  The  victim  finds  that  he 
cannot  depress  the  key  on  account  of  spasm  in  these  muscles, 
and  he  finds  most  difficulty  in  making  the  dot  characters,  such 

as  h  (.  .  .  .),  or  p  ( ),  or  z  (.  .  .     .).     When   the  flexors  are 

most  affected  the  key  is  depressed  with  undue  force  and  a  dash 
is  made  instead  of  a  dot.  Sufferers  from  the  "  loss  of  grip  "  gen- 
erally suffer  from  writers'  cramp  also.  While  spasm  is  usually 
present,  the  disease  may  show  itself  simply  in  pain,  paresis,  and 
incapacity  to  co-ordinate  the  muscles. 

In  sewing  spastn,  which  affects  tailors,  seamstresses,  and  shoe- 
makers, clonic  and  tonic  spasms  attack  the  muscles  of  the  hands 
on  attempting  to  use  them  in  the  regular  work.  Tailors  who  sit 
cross-legged  sometimes  suffer  from  a  peculiar  spasm  on  assuming 
this  position.  It  is  possible,  however,  that  these  are  cases  of 
tetany,  and  not  the  functional  neurosis  under  consideration. 

Smiths''  spasm,  hephcpstic  hemiplegia,  appears  to  have  been 
observed  only  by  Duchenne  and  Dr.  Frank  Smith.  It  occurs  in 
persons  engaged  in  pen-blade  manufacturing,  saw-straightening, 
razor-blade  striking,  scissors-making,  file-forging,  etc.  In  doing 
this  work  they  have  to  use  a  hght  or  heavy  hammer,  with  which 
strokes  are  delivered  very  rapidly  and  carefully.  After  a  time 
spasmodic  movements  occur  in  the  arm  used,  and  the  arm  falls 
powerless.  As  in  the  cases  reported  there  are  generally  hemi- 
plegic  symptoms,  and  also  neuralgias,  vertigo,  and  other  cerebral 
troubles,  the  disease  cannot  be  a  pure  "  occupation  "  neurosis. 

Drivers''  spasm  has  been  observed  in  veterinary  surgeons 
by  Dr.  Samuel  Wilkes. 


PROFESSIONAL  NEUROSES,  OCCUPATION  NEUROSES.      475 

Milkers'  spasm  is  an  extremely  rare  affection,  which  was  first 
described  by  Basedow  and  seems  to  occur  in  milkmaids  never  in 
milkmen.  ' 

Cigar  makers''  cramp  is  very  rare. 

Watchmakers'  cramp  and  photographers'  cramp  are  also  to  be 
regarded  merely  as  pathological  curiosities. 

Ballet-Dancers'  6Va/?i/;.— Under  this  name  certain  painful  and 
paralytic  troubles  occurring  in  ballet-dancers,  especially  premieres 
danseuses,  have  been  described  by  Schultz,  Onimus,  and  Kraus- 
sold.  It  does  not  appear  that  the  trouble  is  really  a  co-ordinative 
functional  one,  but  is  rather  neuralgic,  or  the  result  of  local 
strain  upon  the  parts. 

The  list  of  professional  neuroses  is  made  to  include,  besides 
those  above  given,  cramps  and  co-ordinative  troubles  affecting 
artificial-flower  makers,  billiard- players,  dentists,  hide-dressers, 
electrical-instrument  makers,  stampers,  turners,  sewing-machine 
girls,  money-counters,  weavers,  painters,  and  pedestrians. 

Prophylaxis  and  Treatment.  — T\\q  introduction  of  type- 
writers, gold  pens,  and  improved  penholders  has  prevented  some- 
what the  increase  of  Avriters'  cramp.  Stenographers  rarely  have 
it  unless  they  write  in  long  hand.  Persons  who  have  to  write  a 
great  deal  should  use  large  cork  or  rubber  penholders  and  gold  or 
quill  pens  with  smooth  paper.  The  best  style  of  writing  is  that 
done  from  the  shoulder,  but  this  is  a  method  that  book-keepers 
and  those  who  have  to  keep  accounts  cannot  easily  adopt.  Many 
nervous  persons  have  a  bad  habit  of  gripping  the  pen  very 
tightly  and  pressing  down  on  the  paper  with  excessive  force. 
Fatigue  soon  results  and  painful  sensations  develop  in  the  arm. 
Proper  attention  should  be  paid  to  the  position  of  the  paper 
written  upon,  the  height  of  the  desk,  the  light,  and  the  sleeves 
of  the  coat  or  dress.  The  paper  should  be  laid  at  an  oblique 
angle  to  the  edge  of  the  desk,  and  not  at  a  right  angle  as  many 
writing-teachers  are  accustomed  to  direct.  As  some  cases  of 
"  cramp  "  are  undoubtedly  cerebral,  it  is  very  unwise  to  attempt 
any  extraordinary  exploits  in  writing  or  to  work  with  the  ambi- 
tion to  put  the  writing  capacity  to  the  utmost  test.  Cramp  is 
often  dated  from  days  when  such  extra  work  is  done. 

When  the  cramp  is  fully  developed,  the  most  essential  thing 
is  rest.  This  may  be  secured  by  getting  a  new  form  of  pen- 
holder, holding  the  pen  in  a  different  way,  using  the  unaf- 
fected arm,  using  some  form  of  mechanical  appliance.  The  me- 
chanical appliances  are  splints,  rubber  bands  around  the  wrist, 
and  various  instruments  contrived  to  prevent  spasm  and  throw 
the  work  of  writing  on  new  and  larger  groups  of  muscles. 

Instruments  for  writers'  cramp  are  very  numerous.  Those 
that  are  of  some  value  are  Mathieu's,  Nussbaum's,  and  some  mod- 
ification of  Cazenave's  (see  Figs.  199,  200).  All  the  various  instru- 
ments have  been  of  service,  or  have  even  been  curative  ni  some 


476 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


190.— Mathieu's   Ixstrument 
FOR  Writers''  Cramp. 


special  cases,  but  not  too  much  jnust  be  expected  of  them.  As  a 
rule  they  are  only  paUiative.  A  cheap  instrument  that  may 
prove  satisfactory  is  that  of  Mathieu. 

In  the  medical  treatment  of  writers'  cram^),  the  two  most  im- 
portant agents  are  massage  and  electricity. 

By  massage  only  very  mediocre 
results  were  obtained  until  greater 
attention  was  drawn  to  it  by  Air. 
J.  Wolff,  a  Avriting-master  of  Frank- 
fort-on-the-Main.  This  gentleman 
has  cured  many  cases,  though  not 
all  that  he  has  treated  (Berger),  and 
he  has  secured  many  testimonials 
for  his  method.  The  treatment,  as 
described  by  Schott  (G.  W.  Jacoby), 
consists  of  a  system  of  gymnastics 
and  masage.  The  gymnastics  con- 
sist of  movements  performed  by 
the  i^atient  alone  and  movements 
executed  with  the  co-operation  of  the  operator.  The  first  are 
performed  by  the  patient  during  from  twenty  to  thirty  minutes, 
rarely  for  forty-five  minutes.  These  movements  consist  of  gym- 
nastics of  the  fingers,  extension,  flexion,  abduction,  and  adduc- 
tion V^eing  performed,  and  the  thumb  being  exercised  separately. 
xVfter  this  the  same  four  motions  are  executed  at  the  wrist 
joint,  then  extension  and  flexion  of  the  forearm,  and  ulti- 
mately the  arms  themselyes  are  exercised  in  the  same  manner 
and  are  to  l)e  lifted 
over  the  head.  Each 
single  exercise  is  to 
be  performed  from 
six  to  twelve  times. 
After  each  motion 
a  pause  is  to  V)e  ob- 
served.  The  op- 
posed movements 
are  to  be  carried 
out  in  the  same 
maimer,  except  that  the  operator  must  carefully  resist  their 
execution  as  though  he  were  endeavoring  to  force  the  patient 
to  perform  a  motion  just  the  reverse  of  his  intentions.  Reg- 
ularity of  pressure  is  to  be  observed  in  this,  so  that  the  same 
amount  of  force  is  always  used  and  so  that  the  pressure  does  not 
A'ary  in  intensity  from  moment  to  moment.  The  time  to  be  de- 
voted to  these  opposed  movements  sliould  be  the  same  as  that  for 
the  unopposed  ones.     According  to  the  intensity  of  the  affec- 


FiG.  200.— Nr.<ssBAUM's  In.strument. 


PROFESSIONAL  NEUROSES,  OCCUPATION  NEUROSES.      477 

tion,  the  exercises  must  be  repeated  two  to  three  times  daily. 
The  massage  itself  consists  of  tAvo  parts— nerve  and  muscle 
massage.  The  nerve  massage  is  effleurage  along  the  course  of 
the  nerve  trunks,  the  median,  ulnar,  and  radial,  going  upward 
to  the  axillary  and  cervical  plexuses.  This  effleurage  lasts  about 
ten  minutes.  Following  this  is  the  muscle  massage.  This  con- 
sists of  petrissage,  beginning  with  the  ha.nd  and  ending  at  the 
shoulder.  The  duration  is  the  same  as  that  of  the  last  move- 
ment. One  sitting  a  day  has  always  proved  sufficient.  Wolff, 
in  addition,  uses  "  a  peculiar  method  of  writing  instruction  "  and 
employs  rubber  bands  and  rings  in  his  manipulations. 

Electricity  ranks  second  to  massage  in  the  treatment  of  oc- 
cupation neuroses.  The  faradic  current  may  be  used  when  the 
affection  is  paralytic,  but  the  galvanic  current  is  usually  more 
efficacious.  It  has  been  almost  uniformly  helpful  in  my  experi- 
ence. It  must  be  given  daily,  however,  or  even  twice  a  day.  The 
anode  is  placed  over  the  cervical  spine  and  the  cathode  over  the 
various  muscular  groups  affected.  A  stable  current  of  five  to 
ten  milliamperes  for  from  ten  to  fifteen  minutes  is  given,  (gal- 
vanization of  the  sympathetic  is  recommended  by  some.  Gal- 
vanic belts  applied  about  the  arm  seem  irrational  enough,  but 
have  been  known  apparently  to  effect  cures. 

Lotions  containing  muriate  of  ammonia,  liniments,  hot  and 
cold  douches,  the  cautery,  all  have  been  recommended  in  profes- 
sional neuroses.  Tenotomy  was  once  employed,  but  has  been 
abandoned.  Very  little  can  be  expected  of  drugs.  The  most 
trustworthy  are  atropine,  strychnine,  cannabis  indica,  the  io- 
dides and  bromides,  and  cod-liver  oil.  It  should  be  remem- 
bered that  sometimes  the  disease  is  almost  purely  cerebral,  and 
then  an  anti-neurasthenic  treatment  is  called  for.  But  in  other 
cases,  when  the  disorder  is  largely  peripheral,  the  usual  treat- 
ment for  a  low  grade  of  myoneuritis  must  be  employed. 


CHAPTER  XXyi. 

PARALYSIS   AGITANS   (SHAKING   PALSY,   PARKIN- 
SON'S  DISEASE). 

Paralysis  agitans  is  a  chronic  progressive  disease,  character- 
ized by  tremor,  muscular  rigidity  and  weakness,  and  by  a  pecul- 
iar attitude  and  gait  together  with  sensations  of  heat,  pain,  and 
restlessness. 

Etiology. — It  occurs  oftenest  between  the  ages  of  fifty  and 
sixty,  then  between  sixty  and  seventy  and  forty  and  fifty.  In 
very  rare  instances  it  occurs  in  early  life,  but  the  genuine  disease 
does  not  occur  before  puberty.  Males  are  afiected  much  oftener 
than  females  (five  to  three  in  seventy-eight  American  cases).  It 
occurs  in  all  clases  of  life,  but  oftener  among  those  who  incur 
exposures  and  endure  hard  labor.  It  is  not  a  disease  of  vice 
and  is  not  the  result  of  alcoholism,  syphilis,  or  sexual  excess. 
Heredity  is  a  rare  factor,  but  I  have  known  hereditary  family 
tremor  to  end  in  paralysis  agitans.  It  appears  to  have  some 
relation  to  rheumatism  and  especially  to  rheumatoid  arthritis. 
It  occurs  oftenest  in  this  city  among  the  Irish,  German,  and 
Polish  races  (twenty  Irish,  thirteen  Germans  and  Russians,  the 
last  mostly  Hebrews). 

The  exciting  causes  in  the  majority  of  cases  are  exposure  to 
wet  and  cold,  fright,  injury,  and  prolonged  mental  anxiety. 
An  attack  of  sciatica  or  rheumatism,  a  sudden  severe  muscular 
strain,  and  fevers  are  rare  causes.  I  have  never  been  able  to 
trace  a  case  to  malaria. 

Symptoms. — The  disease  usually  begins  slowly  with  some  ach- 
ing pains  in  the  arm  and  a  slight  tremor  in  the  fingers  of  one 
hand,  oftener  the  left.  This  gradually  extends  and  involves  the 
foot  of  the  same  side,  then  the  other  side  becomes  affected.  The 
neck,  face,  and  tongue  are  rarely  attacked,  and  then  to  a  small 
extent.  After  or  with  the  tr(?mor  there  comes  on  a  stiffness  in 
the  arms  and  legs,  and  indeed  of  the  whole  body.  AVith  this 
there  is  a  general  contracturing  and  shortening  of  all  the  flexor 
groups;  so  that  the  head  and  body  are  bent  forward,  the  fingers 
are  straight  but  are  flexed  as  a  whole  on  the  metacarpus,  the  fore- 
arms flexed  on  the  arm,  tlie  trunk  flexed  forward  on  the  thighs, 
and  the  knees  slightly  bent.  The  attitude  gives  the  idea  of  ex- 
treme senility  (Fig.  201).     The  gait  is  slow,  the  steps  short  and 


PARALYSIS   AGITANS. 


479 


shuffling;  the  patient  has  trouble  in  starting,  stopping,  and  turn- 
ing corners,  owing  to  the  slowness  in  initiating  new  movements 
in  the  voluntary  muscles.  When  once  started  he  may  be  unable 
to  stop  and  has  to  run  along.  The  siDeech  early  becomes  affected. 
The  voice  is  high-pitched,  weak,  and  piping  or  senile  in  quality. 
There  is  a  slowness  in  getting  out  words  or  in  starting  a  sentence, 
though  after  it  is  begun  the  words  come  rapidly.  The  condition 
is  analogous  to  the  hesitation  in  the  gait. 

Along  with  the  other  symptoms  there  are  often,  though  not 
always,  sensations  of  heat,  burning,  fever,  and  rarely  of  coldness. 
These  sensations  are  felt  most  in  the  feet,  legs,  or  arms  diffusely. 
Often  there  is  a  general  feeling  of  restlessness  and  nervousness. 


Fig.  201. — Attitude  and  Gait  in  Paralysis  Agitans. 


Aching  pains  and  a  sense  of  fatigue  occur;  neuralgic  pains 
are  more  rare.  There  is  always  a  peculiar  redness  and  flush 
in  the  faces  of  the  patients.  Sometimes  they  sweat  profusely. 
Their  temperature  in  the  axilla  is  normal,  on  the  skin  it  is 
sometimes  increased  (Peterson).  The  appetite  is  excellent, 
often  abnormally  great,  and  digestion  is  good.  Visceral  compli- 
cations are  rare.  Muscular  weakness  comes  on  early ;  it  slowly 
increases,  but  complete  muscular  paralysis  does  not  occur.  The 
disease  ends  in  rigidity,  which  makes  the  patient  as  helpless  as  if 
paralyzed,  but  the  muscles  preserve  considerable  functional 
power  to  the  last.  The  deep  reflexes  are  present  and  not,  as  a 
rule,  exaggerated;  but  exaggeration  and  even  clonus  occur  in 
a  small  percentage  of  cases.  As  the  disease  progresses  the  tre- 
mor increases  in  extent,  and  continues  without  remission  dur- 
ing all  the  waking  hours;  the  limbs  get  more  rigid;  the  patient 
becomes  bedridden  and  is  finally  carried  off  by  exhaustion  or 
some  intercurrent  illness  (Fig.  202). 


4S0  DISEASES   OF   THE   NERVOUS   SYSTEM. 

It  ^vill  V)e  seen  that  the  dominant  symptoms  in  paralysis  agitans 
are : 

1.  Tremor. 

2.  Rigidity,  i)rogressively  increasing. 

3.  Sensory  and  vasomotor  disturbances. 

Farther  details  must  be  given  regarding  these  symptoms: 
The  tremor  is  at  first  rather  fine,  but  later  is  coarse.  It  ranges 
from  about  G  vibrations  per  second  to  o.T.  The  average  rajiidity 
is  4  or  5  per  second,  which  is  about  one-half  the  normal  muscular 
rhythm.  But  the  chief  characteristic  of  the  tremor  is  that  it 
continues  when  the  hand  or  limb  is  at  rest,  while  voluntary 
motion  causes  it  to  cease.  As  the  hand  rests  on  the  knee  it 
shakes ;  as  it  is  moved  the  tremor  stops.  When  held  straight  out 
there  is  no  shaking  for  a  moment,  but  it  soon  begins.  A  glass  of 
water  is  carried  safely  to  the  lips.  The  patient  can  control  the 
tremor  for  a  moment,  especially  in  the  early  stages  of  the  disease. 
These  facts  about  the  tremor  apply  in  ninety  per  cent  of  cases. 
But  there  are  patients  whose  tremor  is  slight  w^hen  the  limb  is 
at  rest  and  is  increased  on  voluntary  effort.  The  hands  are 
affected  in  a  characteristic  way.  The  fingers  and  thumb  are 
slightly  flexed  and  held  about  in  the  writing  position;  the 
tremor  moves  the  fingers  and  thumb  as  a  whole,  and  they  vi- 
brate so  that  the  one  pats,  the  other  gently.  Sometimes  the 
tremor  is  one  of  alternate  suiDination  and  pronation  of  the  fore- 
arm. The  neck  and  face  muscles  are  not  usually  or  extensively 
involved,  the  shaking  of  the  head  being  generally  the  result 
of  the  general  bodily  tremor.  Sometimes  one  sees  a  tremor  of 
the  lips  or  neck  muscles.  The  tongue  and  eye  muscles  are  prac- 
tically never  involved. 

Rigidity. — The  tremor  may  be  almost  or  even  entirely  absent 
in  this  disease.  If  so,  there  is  a  corresponding  dominance  of 
the  sj'mptom  of  rigidity.  The  rigidity,  as  stated,  comes  on  early, 
and  may  be  the  first  and  even  the  only  prominent  symptom.  It 
affects  chiefly  the  flexors  of  the  arms,  head  and  trunk,  and  legs, 
producing  a  characteristic  senile  position.  In  rare  cases  the  ex- 
tensors of  the  neck  are  affected  and  the  head  is  drawn  back. 
Cramps  occur,  and  there  is  always  a  sense  of  stiffness.  The  mus- 
cular movements  are  slow,  especially  the  initiation  of  a  move- 
ment. Once  started,  a  motion  may  be  quickly  done.  The  gait  is 
peculiar:  the  steps  are  short  and  shuffling;  the  patient  may  have 
difficulty  in  starting,  but  once  started  he  goes  along  well;  or 
while  walking  there  may  be  a  sudden  running  forward.  This  is 
called  "  festination."  Rarely  there  i«  a  tendency  to  run  backward 
or  sidew^ays.  The  facial  nuiscles  are  stiffened  and  little  used,  so 
that  the  face  has  a  peculiar  expressionless  look.  The  patient  is 
often  emotional,  but  the  mind    is  not  seriously  affected.     The 


PARALYSIS   AGITANS. 


481 


urine  is  usually  about  normal,  but  contains  an  excess  of  phos- 
I^hates.     There  may  be  polyuria  and  less  often  glycosuria. 

Course  and  Duration.— The  disease  slowly  but  steadily  pro- 
gresses until  a  full  development  of  symptoms  occurs,  when  it  may 
remain  stationary.     It  takes  about  two  years  for  the  whole  body 


I 


Fig.  202— Terminal  Stage  op  Paralysis  Agitans,  showing  rigidity  and 
contractures. 

to  be  affected,  though  this  varies  much.  It  lasts  from  three  to 
twelve  years.  In  three  cases  of  mine  death  occurred  in  three,  six, 
and  eleven  years.  It  may  last  for  thirty  years  or  even  more. 
Death  is  due  to  exhaustion  and  may  be  accompanied  with  mild 
delirium  and  fever. 

The  diagnosis  must  be  made  from  senile  tremor,  multiple 
sclerosis,  post-hemiplegic  tremor,  and  wry-neck  affecting  the  ex- 
31 


482  DISEASES   OF  THE   NERVOUS   SYSTEM. 

tensors  bilaterally  (retrocoUic  spasm).  Senile  tremor  occurs  in 
the  very  old  and  affects  the  head  first  and  most.  In  multiple 
sclerosis  the  tremor  is  more  jerky  and  is  a  tremor  of  motion ;  there 
is  nystagrmus,  syllabic  speech,  and  often  apoplectiform  attacks, 
eye  trouble,  and  paralyses. 

Post-hemiplegie  tremor  is  accompanied  with  a  history  of  hemi- 
plegia ;  there  are  paralysis  and  exaggerated  reflexes  and  the  disease 
is  unilateral.  In  retrocollic  spasm  only  the  neck  muscles  and 
frontalis  are  involved.  The  absence  of  exaggerated  reflexes,  the 
peculiar  voice,  gait  and  attitude,  and  the  sensations  of  heat  and 
nervousness  often  help  greatly  in  the  diagnosis. 

The  prognosis  is  favorable  as  regards  life;   unfavorable  as 


I- 


Fig.  203.— Anterior  Horn  of  Spinal  Cord,  showing  dilated  capillaries. 

regards  cure;  moderately  good  as  to  bringing  about  a  cessation 
of  i^rogress  in  the  symptoms. 

Pathology. — The  following  are  among  the  changes  that  have 
been  found  in  the  central  nervous  system:  Hypertrophy  of  the 
nerve  cells  of  the  pons,  induration  of  the  pons,  medulla,  and  cord, 
thickening  of  blood-vessel  M'alls  and  of  the  pia  mater,  increase 
of  connective  tissue  in  the  motor  tracts,  nerves,  and  muscles.  In 
some  cases  autopsies  have  revealed  nothing.  The  most  constant 
change  described  is  an  increase  of  connective  tissue  in  the  motor 
tracts  and  pons,  with  congestion  and  hyperplasia  of  the  vessel 
walls.  I  have  found  a  peculiar  dilatation  of  the  vessels  of  the 
anterior  cornua  and  roots,  with  some  atrophy  of  motor  cells 
(Figs.  203,  204). 


PARALYSIS   AGITANS.  483 

Everything  points,  howev^er,  to  the  seat  of  the  disease  being 
primarily  in  the  upper  motor  or  cerebro-spinal  segment. 

Forms.— The  unusual  types  of  paralysis  agitans  are  the  hemi- 
plegic  or  the  monoplegia,  the  rigid  type,  and  the  retrocollic  type. 
The  only  one  of  importance  is  the  rigid  type,  in  which  there  is 
practically  no  tremor. 

Treatment. — The  most  important  measure  is  rest,  mental  and 
physical,  with  plenty  of  fresh  air.  No  special  diet  is  indicated. 
Lukewarm  baths  and  mild  massage  are  agreeable  and  helpful. 
1  know  of  no  climatic  cure.  The  galvanic  current  produces  tem- 
porary relief ;  it  should  be  given  daily.  Hyoscine  hydrobromate, 
first  used  by  Charcot  and  introduced  into  this  country  by  Seguin, 
is  of  much  temporary  value  in  relieving  the  tremor  (gr.  j^  in- 


^ 


Fig.  204. — Showing  Atrophied  Cells. 


creased).  Codeia  and  morphine  give  the  best  permanent  results. 
Quinine  and  mineral  acids  are  of  much  service  in  relieving 
the  vasomotor  and  sensory  symptoms.  I  have  used  bromide  of 
uranium  (gr.  -^q)  with  some  apparently  good  results.  Arsenic, 
Indian  hemp,  tinct.  veratrum  viride,  salicin,  and  salicylate  of 
soda  rank  next  in  value.  Nitrate  of  silver,  conium,  curare,  bro- 
mides, atropia,  phosphorus,  cod-liver  oil,  iron,  and  picrotoxin 
have  all  been  recommended.  They  are  of  doubtful  value.  Sus- 
pension is  of  some  use  in  a  minority  of  cases  not  too  much  ad- 
vanced. The  mind  in  i^aralysis  agitans  is  sometimes  in  an  emo- 
tional, almost  hysterical,  condition,  and  patients  are  easily  made 
better  for  a  time  by  some  jDsychical  influence.  Hypnotism  by 
means  of  fascination  is  said  to  be  of  use,  but  it  has  failed  in  my 
experience. 


CHAPTER  XXYIT. 

TROPHIC  A^B  VASOMOTOR  DISORDERS. 

Progressive  facial  hemiatrophy  is  a  disease  c-liaracter- 
ized  by  a  progressive  wasting  of  one  side  of  the  face. 

Etiology.— \t  begins  oftenest  in  the  young  between  the  ages 
of  ten  and  twenty.  Females  are  more  affected."*  There  is  in 
rare  eases  a  hereditary  history.  Injury  and  infectious  fevers 
sometimes  start  up  the  trouble.     The  left  side  is  oftener  attacked. 


Fto. 


Facial    Hemiatrophy 


Early   Stage,    showing  alopecia   and    osseous 
depressions. 


/Symptoms.— The  disease  begins  very  gradually  and  shows 
itself  first  in  patches.  The  skin  gets  thinner,  there  is  loss  of  pig- 
ment, hairs  fall  out,  and  the  areas  may  have  a  yellowish  appear- 
ance. Sometimes  the  periosteum  and  bone  are  affected,  and  shal- 
low depressions  are  formed  which  may  be  anaesthetic  (Fig.  205). 
The  subcutaneous  tissue  is  most  involved,  the  muscles  least,  and 
there  are  no  changes  in  electrical  reaction.  The  muscles  of  mastica- 

*  About  100  cases  have  been  reported.  Among  5  seen  by  myself,  3  were  in 
females,  2  in  males.  The  disease  in  all  cases,  so  far  as  could  be  found,  began  between 
the  tenth  and  twentieth  years. 


TROPHIC   AND   VASOMOTOR   DISORDERS.  485 

tion  are  usually  spared.  The  bone  undergoes  general  atrophy 
and  the  lower  jaw  may  be  reduced  to  two-thirds  the  normal  size. 
The  secretion  of  sebum  ceases,  but  that  of  sweat  may  be  increased. 
The  temperature  falls.  There  is  a  sinking  in  of  the  eye,  nar- 
rowing of  the  lid,  and  dilatation  of  the  pupil.  There  is  some- 
times pain  and  rarely  anaesthesia.  The  tongue  and  other  parts 
of  the  body  may  be  involved.  Spasmodic  movements  of  the 
muscles  of  mastication  have  been  noted  (B,  Sachs).  Scleroderma 
sometimes  aj^pears  on  the  face  or  hands. 

The  disease  progresses  rather  rapidly  at  first,  but  finally  comes 
to  a  standstill.     It  does  not  shorten  life. 

Fatkology.— There  has  been  found  a  degenerative  neuritis  in- 
volving the  fibres  of  the  trigeminus ;  its  descending  root  and  the 
substantia  nigra  were  atrophied  (Mendel). 

The  diagnosis  is  easy.  Hemiplegia  with  atrophy  in  children, 
congenital  asymmetry,  and  atrophy  from  gross  lesions  of  the 
nerve  are  distinguished  by  their  stationary  character  or  the  pres- 
ence of  severe  pain. 

Treatment. — There  is  no  treatment  known  to  be  of  service. 
Tonics,  iodide,  and  electricity  may  be  tried.  Dercum  has  sug- 
gested resectins:  the  tria^eminal  nerve. 


Acuo:.iEGALY  (Marie's  Disease), 

Acromegaly  is  a  chronic  dystrophy  characterized  by  gradual 
enlargement  of  the  hands,  feet,  head,  and  thorax,  and  by  a  dorso- 
cervical  kyphosis.  Though  the  disease  was  first  described  only 
six  years  ago  by  P.  Marie,  the  number  of  cases  reported  is  rapidly 
increasing,  and  if  one  includes  various  abortive  types  it  is  not 
extremely  rare.     Eleven  American  cases  have  been  recorded. 

Etiology. — It  affects  the  two  sexes  nearly  alike.  It  begins 
between  the  ages  of  eighteen  and  twenty-six ;  recently  a  congen- 
ital case  has  been  reported.  JN^o  hereditary  influence  or  definite 
exciting  cause  is  known.  The  patients  are  sometimes  naturally 
endowed  with  large  extremities. 

^i/mptoms. — The  disease  begins  with  a  gradual  enlargement  of 
the  hands,  feet,  and  head.  In  women  there  is  amenorrhoea,  in 
men  sexual  weakness ;  slight  rheumatic  pains,  headaches,  malaise, 
mental  hebetude,  anaemia,  and  general  weakness  are  present. 
The  skin  is  dry  and  there  is  polyuria. 

The  hypertrophy  affects  the  soft  parts  as  well  as  bones.  In 
these  latter  there  is  periosteal  thickening  and  hyperplasia,  with 
the  result  of  jiroducing  increase  in  width  more  than  length.  The 
arms  are  not  much  involved,  nor  is  the  shoulder  girdle,  except  the 
clavicle.  The  lower  jaw  is  much  more  involved  than  the  cra- 
nium. The  tongue,  lips,  and  nose  are  enormously  hypertro- 
phied.  The  thorax  is  enlarged  antero-posteriorly  and  flattened. 
There  is  sometimes  dulness  over  the  sternum  due  to  persistence 
of  the  thymus.  The  pelvis  may  be  enlarged,  but  the  hip  and  leg 
bones  are  generally  spared.  The  feet  undergo  enormous  hyper- 
trophy.    The  following  are  some  of  the  measurements  in  the  case 


480 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


that  has  come  under  my  observation,   reported  by  Adler,  and 
in  cases  reported  by  Osborne  and  Packard : 

Lenj^th  of  hand,       .        .  .  7.G  to    8|  inches. 

Length  of  foot,  ....  11.7  to  12i      " 

Cranial  circumference,    .         .        .  24     to  20^ 

Circumference  of  thorax,         .        .  44 

The  vision  is  sometimes  impaired  and  there  may  be  hemi- 
anopsia. The  muscles  may  be  at  first  hypertrophied,  later  atro- 
phied.    There  are  no  paralyses  and  rarely  any  ansesthesice. 

The  disease  runs  a  veiy  chronic  course,  lastino^  ten  or  twenty 
years. 


Fig.  20G. — Acromegaly. 


Pathology. — There  has  been  found  an  enlargement  of  the  pitu- 
itary body,  and  it  lias  been  suggested  that  the  disease  is  due  to 
disorder  of  its  function.  But  this  enlargement  is  not  constant, 
and  tumor  of  this  organ  does  not  cause  acromegaly.  The  at- 
tempts to  place  the  disease  in  relation  with  a  persistent  thymus, 
sclerotic  changes  of  the  sympathetic,  and  disease  of  the  thyroid, 
all  of  which  conditions  have  heau  found,  are  equally  unsuccess- 
ful. The  disease  must  be  regarded  as  a  perversion  of  nutrition 
of  unknown  origin.  The  enlargement  of  the  bones  is  a  true 
hypertrophy,  not  an  inflammation. 

The  (li((f/nosis  must  be  made  frorn  congenital  enlargements, 
from  so-called  giant  growth  which  affects  single  members,  and 
from  osteitis  deformans.  In  the  latter  disease  it  is  the  shafts  of 
the  long  bones  and  the  cranium,  not  the  face,  which  are  involved. 

Pnenmogenia  ostt^o-arthropathn  is  the  name  given  by  Marie 
to  a  disease  associated  with  pulmonary  and  pleuritic  disease,  and 


TROPHIC   AND   VASOMOTOR   DISORDERS.  487 

characterized  by  enlargement  of  the  extremities  and  peculiar 
deformities  of  the  terminal  phalanges.  The  enlargements  are  not 
uniform.  The  tongue  is  not  affected.  The  wrist  and  ankle  bones 
are  hypertrophied,  the  finger-tips  are  bulbous  and  spade-shaped. 

PrognQsls. — Acromegaly  is  incurable,  but  it  has  been  arrested, 
or  at  least  has  ceased  to  progress,  and  it  may  not  greatly  shorten 
life. 

Treatment. — Cases  have  been  reported  in  which  iodide  of 
potassium  and  arsenic  have  arrested  the  disease.  In  general,  the 
treatment  is  only  symptomatic. 

Angioneurotic  (Edema  (Circumscribed  CEdema). 

Angioneurotic  oedema  is  a  functional  disorder  characterized  by 
the  rather  rapid  appearance  of  circumscribed  swellings  upon 
different  parts  of  the  body,  these  swellings  being  due  to  disturb- 
ances of  vasomotor  innervation  and  not  of  an  inflammatory 
character.  The  disease  occurs  oftenest  in  early  adult  life,  the 
average  age  being  from  twenty  to  thirty,  but  it  has  been  observed 
in  young  children  and  even  in  the  aged.  It  occurs  oftener  in 
males  than  in  females,  except  in  this  country,  where  the  reverse 
ratio  exists.  Hereditary  influence  plays  a  part  in  some  cases ;  the 
disease  has  been  known  to  run  in  families.  It  occurs  oftener  in 
winter  and  oftener  in  the  early  morning  hours.  Exhausting  oc- 
cupations predispose  to  it.  The  exciting  causes  are  sudden  expo- 
sure to  cold,  slight  traumatisms,  fright,  anxiety,  grief,  and  the 
ingestion  of  certain  kinds  of  food  such  as  apples  or  fish.  A  pecu- 
liar form  of  this  oedema  seems  to  develop  in  connection  with 
menstruation. 

Symptoms. — The  disease  appears  without  much  if  any  warn- 
ing. In  a  few  minutes  or  hours  there  develops  a  circumscribed 
swelling  upon  the  face  or  arms  or  hands.  This  swelling  varies 
in  diameter  from  one-half  inch  to  two  or  three  inches.  It  may 
be  dark  reddish  or  rosy  or  it  may  be  pale  and  waxy.  It  does  not 
easily  j)it  on  pressure.  There  is  sometimes  a  local  rise,  sometimes 
a  fall  in  temperature.  It  is  accompanied  with  sensations  of  ten- 
sion and  stiffness,  scalding,  burning,  and  sometimes  itching,  but 
there  is  no  actual  pain.  The  swelling  is  usually  single,  but  it 
may  be  multiple.  It  is  located  most  often  upon  the  face,  next 
upon  the  extremities,  particularly  the  hands;  next  on  the  body, 
then  in  the  larynx  and  throat,  and  then  on  the  genitals.  The 
swellings  last  from  a  few  hours  to  tAvo  or  three  days.  Between 
the  attacks  the  patient  feels  well.  They  are  aijt  to  return  at 
intervals  of  three  or  four  weeks  to  several  months.  Sometimes 
they  are  only  brought  out  by  certain  peculiar  exciting  causes, 
such  as  indigestion  or  mental  anxieties  or  emotional  disturbances. 
When  the  disease  attacks  the  larynx  or  throat,  serious  symptoms 
of  dyspnoea  and  suffocation  may  appear;   surgical  interference 


488  DISEASES   OF  THE   NERVOUS   SYSTEM. 

may  even  be  called  for,  and  death  has  been  known  to  result.  It 
has  been  thought  that  neurotic  a^denia  may  sometimes  attack 
the  stomach,  producing  symptoms  of  nausea,  vomiting,  and  great 
gastro-intestinal  distress,  and  an  acute  neurotic  oedema  possibly 
sometimes  attacks  the  lungs.  This,  however,  is  unlikely,  since 
the  vasomotor  innervation  of  the  pulmonary  blood-vessels  is  a 
very  stable  one. 

The  pathology  ot  the  disease  is  not  known,  except  that  it  is 
unquestionably  a  disorder  due  primarily  to  disturbance  in  nerve 
innervation.  The  nerves  affected  are,  furthermore,  undoubtedly 
vasomotor  nerves.  The  oedema  is  precisely  similar  to  that  which 
is  associated  with  attacks  of  tic  douloureux  and  migraine. 

Diagnosis.— ThQ  symptoms  of  the  disease  are  so  peculiar  that 
they  are  easily  recognized.  The  spontaneous  appearance  of  the 
oedema,  its  recurrence  at  certain  intervals,  and  the  absence  of 
pain  and  evidences  of  inflammation  are  sufficient  usually  to  en- 
able us  to  recognize  it.  The  giant  urticaria  is  a  disease  resem- 
bling neurotic  oedema  and  probably  closely  allied  to  it.  The  blue 
and  the  white  oedema  of  hysterics  differs  in  being  persistent  and 
associated  with  paralyses,  anaesthesias,  and  contractures. 

The  prognosis,  so  far  as  cure  is  concerned,  is  not  very  good. 
The  attacks,  however,  can  be  ameliorated,  and  the  disease  itself 
is  not  serious  as  regards  life  and  the  enjoyment  of  a  fair  degree  of 
general  health. 

The  treatment  consists  in  the  adoption  of  such  measures  as 
will  give  tone  and  stability  to  the  nervous  system ;  the  use  of  cold 
baths,  exercise,  and  massage  is  indicated.  Internally  mineral 
acids  and  strychnine  may  be  of  some  value.  Cascara,  nux  vomica, 
the  salicylates,  arsenic,  quinine,  and  atropine  are  all  drugs  which 
have  been  recommended. 


CHAPTER  XXYIII. 

THE  DISORDERS   OF   SLEEP. 

iNSOMmA,  Hypnotism,  Morbid  SoM^fOLExcE,  Catalepsy, 
Trance,  Lethargy,  the  Sleeping  Sickness. 

Sleep  is  a  condition  in  which  consciousness  is  normally 
lost  and  in  which  the  whole  body,  but  particularly  the  brain, 
enjoys  functional  rest,  while  constructive  and  nutritive  activity 
goes  on. 

Physiology.— The  most  conspicuous  phenomenon  of  sleep  is 
the  subsidence  of  the  higher  cerebral  functions;  yet  other  organs, 
notably  the  muscular  system,  also  take  part  in  the  resting  pro- 
cess. The  brain  during  sleep  is  slightly  anaemic,  the  deficiency 
in  blood  being  a  part  of,  but  not  the  cause  of,  the  phenomenon. 
The  remote  cause  of  sleep  is  inherent  in  the  nervous  tissue  itself, 
which  follows  the  great  rhythmical  law  common  to  all  living 
tissue  of  rise  and  fall  in.  its  irritability.  It  is  probable  that 
the  immediate  cause  of  drowsiness  is  the  exhaustion  of  the  ir- 
ritability of  the  cortical  cells  and  the  benumbing  of  them  by 
the  circulation  of  waste  i^roducts  in  the  blood.  Many  facts 
in  the  history  of  the  pathology  of  the  brain  point  to  the  ex- 
istence of  a  sleep  centre,  which,  being  especially  acted  upon, 
tends  to  inhibit  the  consciousness  and  draw  the  mind  into  a 
somnolent  state. 

As  sleep  is  only  a  function,  we  cannot  speak  of  its  diseases, 
but  only  of  its  disorders,  and  these  really  form  but  a  part  of  the 
diseases  of  the  brain  or  of  general  diseases.  It  is  a  matter  of 
convenience,  however,  to  discuss  some  of  these  separately. 

Classiflcation. — Custom  has  established  the  use  of  certain 
terms  for  the  various  disorders  of  sleep,  and  such  terms  must  be 
for  the  most  part  adhered  to.  It  will  be  proper,  however,  for  the 
sake  of  completeness,  to  arrange  the  various  disturbances  we 
are  to  discuss  in  accordance  with  the  modern  methods  of  study- 
ing the  pathological  changes  of  bodily  functions.  We  propose, 
therefore,  the  following  classification,  which  indicates  the  va- 
rious depressions,  exaltations,  and  perversions  of  the  function 
of  sleep : 


4'.»0  DISEASES   OF   THE   NERVOUS   SYSTEM. 

I.  State  of  normal  sleep.    Hypnosis.  Somnus. 

II.  States  of  absence  of  sleep.    Ahyj)-       Insomnia. 
nosis. 

III.  States   of   perverted   or   artificial*      Dreams,     nightmare,     night-terrors, 
sleep.    Parahyjmosis.  sleep  -  drunkenness,     somnambulism, 

hypnotism. 

IV.  States   of    excessive   or    frequent       Morbid  soumolence,  paroxysmal  sleep, 
drowsiness  and  sleep.    Hyperhypnosis.  epileptic  sleeping  attacks,  trance-sleep, 

lethargj',  sleeping-sickness  of  Africa. 

I,  Normal  sleep  varies  much  in  accordance  with  age,  sex, 
the  individual,  and,  to  a  slight  extent,  with  occupation,  race,  and 
climate.  The  infant  sleeps  fourteen  or  sixteen  hours  out  of  the 
twenty-four,  the  adult  needs  about  eight  hours,  while  the  aged 
live  healthfully  with  but  six.  Women  need  half  an  hour  or  an 
hour  more  than  men.  A  few  persons,  generally  men,  need  nine, 
ten,  or  even  twelve  hours  of  sleei)  daily ;  others  require  only  six. 
Brain-workers,  as  a  class,  take  less  sleep  than  laborers.  Sleep  is 
sounder  and  longer  in  cold  chmates  and  among  northern  races. 

II.  IxsoMXiA  is  a  term  given  to  conditions  in  which  persons 
simply  suffer  from  insufficient  and  restless  sleep  or  from  entire 
absence  of  sleep  for  a  long  time.  Such  conditions  result  from  a 
great  variety  of  causes.  It  is  my  purpose  to  discuss  only  those 
forms  in  which  the  trouble  is  functional  or  nutritional,  leaving 
out  of  consideration  the  symptomatic  insomnia  of  organic  brain 
disease  and  that  occurring  as  the  result  of  painful  diseases. 

An  entire  absence  of  the  capacity  to  sleep  occurs  most  often 
and  typically  at  the  onset  or  in  the  course  of  insanity.  It  is  here  a 
prominent  and  most  distressing  sj'mptom.  The  length  of  time 
during  which  a  person  can  live  without  any  sleep  is  about  the 
same  as  that  during  which  he  can  go  without  food,  viz.,  three 
weeks.  Many  hysterical,  neurasthenic,  or  incipiently  insane  in- 
dividuals Mill  assert  that  they  have  not  slept  for  weeks,  but  care- 
ful examination  shows  that  they  have  at  least  been  in  a  drowsy, 
sonniolent  condition,  which  is,  in  a  measure,  physiologically 
equivalent  to  sleep. 

Etiolo(jiJ. — The  cases  in  which  i^ersons  can  only  get  a  troubled 
rest  of  a  few  hours  are  much  more  numerous.  It  is  a  dis- 
order of  the  third,  fourth,  and  fifth  decades  of  life.  Women 
are  less  liable  to  suffer  from  it  than  men,  and  the  laboring 
classes  less  than  those  engaged  in  business  or  professional  pur- 
suits. A  frequent  symjitom  of  neurasthenia  is  an  imperfect, 
and  especially  an  unre.sting,  sleep.  In  these  neurasthenic  cases 
there  is  a  loss  of  vasomotor  tone.  In  gout  and  in  the  so-called 
latent  gout,  or  litluemia,  insomnia  is  a  frequent  symptom. 
One  of  the  few  nervous  symptoms  of  secondary  syphilis  is  in- 
somnia. Insomnia  may  develop  as  a  bad  nervous  habit  in  per- 
sons who  are  neglectful  of  themselves.    It  occurs  sometimes  as  an 


THE   DISORDERS   OF  SLEEP.  491 

hereditary  neurosis.  I  am  acquainted  with  a  family  in  which, 
for  four  generations,  one  or  more  of  the  members  have  suffered 
from  chronic  insomnia  throughout  hfe.  In  anaemia  and  chlorosis 
there  is  often  insomnia  at  night,  combined  with  somnolence  dur- 
ing the  day-time.  Disease  of  the  heart  and  arteries  may  lead  to 
insomnia,  and  under  this  head  come  the  cases  which  occur  in 
Bright's  disease  with  tense  arteries  and  anaemic  brains.  Disorders 
of  the  stomach  lead  to  disturbed  sleep  oftener  than  complete  in- 
sonniia,  and  the  liver,  when  inactive,  causes  somnolence  rather 
than  the  contrary.  The  poison  of  malaria  and  the  toxic  agents 
of  fever  must  be  added  to  the  list  of  causes  of  imperfect  sleep. 

It  will  be  seen  that  the  causes  of  chronic  functional  insomnia 
may  be  classed  under  the  following  heads : 

1.  Neurasthenic  and  vasomotor,  including  hereditary  and 
habit  insomnia. 

2.  Vascular  and  cardiac,  including  heart  disease,  arterial  fibro- 
sis, and  general  anemia. 

;3.  xiuto-toxic  or  diathetic,  including  lithaemia,  gout,  and  urae- 
mia. 

4.  Toxic,  including  syphilis,  lead,  malaria,  tobacco,  and  vari- 
ous drugs,  such  as  coffee,  tea,  and  coca. 

In  many  cases  there  exists  a  combination  of  these  causes. 

Symptoms. — The  forms  and  degrees  of  insomnia  vary  greatly. 
In  children  it  is  accompanied  usually  with  much  mental  and 
physical  disturbance.  The  patient  is  restless,  excited,  talkative, 
or  querulous  and  irritable.  The  insomnic  child  is  more  ill  than 
the  insomnic  adult.  In  neurasthenic  insomnia  there  is  a  tumult 
of  thoughts  which  prevent  sleep,  or  sleep  is  superficial,  unresting, 
and  interrupted  by  dreams.  In  many  cases  of  insanity  insomnia 
is  characterized  by  great  motor  restlessness.  In  old  people  in- 
somnia is  generally  of  the  quiet  kind. 

Treatment. — As  insomnia  in  all  its  phases  is  often  a  symptom 
of  some  general  disorder,  treatujent  of  a  curative  kind  must  be 
directed  to  this.  Anaemia,  lithaemia,  uraemia,  malaria,  and  the 
other  toxic  influences  must  be  removed  by  remedies  adapted  to 
these  conditions.  But  besides  constitutional  treatment  there  is 
a  symptomatic  treatment  which  will  be  discussed  here. 

The  older  physicians,  in  treating  insomnia,  used  to  depend 
largely  on  hyoscyamus,  camphor,  opium,  and  the  fetid  drugs, 
such  as  asaf(Btida,  musk,  and  valerian.  Hyoscyamus  is  still  used. 
It  is  to  be  given  in  large  doses,  such  as  five  or  ten  grains  of  the 
extract,  or  even  more,  and  from  ten  to  twenty  drops  of  the  fluid 
extract.  The  hydrobromate  of  hyoscin,  in  doses  of  gr.  yfo  to  gr. 
ifo  or  more,  is  one  of  the  best  forms.  Hyoscin  is  indicated  in 
the  insoumia  of  the  insane,  especially  in  forms  accompanied  with 
motor  activity.     Chloral  hydrate  still  holds  its  own  as  one  of  the 


492  DISEASES   OF  THE   NERVOUS   SYSTEM. 

surest  of  hypnotics.  The  dangers  hivolved  in  its  use  have  ^^een 
somewhat  exaggerated,  though  they  are  sufficiently  real.  Doses 
of  gr.  X.  and  gr.  xv.  are  often  quite  large  enough,  but  in  alcoholic 
insomnia  it  may  be  given  in  twice  the  above  amounts,  guarded 
with  ammonia  and  digitalis.  ]S'ot  a  few  persons  find  that  chloral 
has  bad  efifects.  The  patient  awakes  with  a  dull,  heavy  sensation 
in  the  head,  slight  headache,  or  gastric  disturbance. 

The  various  bromides  are  efficient  and  safe  hypnotics  if  prop- 
erly used.  The  immediate  effect  of  them  is  simply  sedative,  and 
sleep  is  not  produced  unless  very  large  doses  are  given.  Some 
persons  are  even  kept  awake  by  average  doses  (gr.  xv.  to  xx.).  In 
insomnia,  therefore,  bromides  are  best  prescribed  in  doses  of 
gr.  XV.  three  times  a  day.  By  the  second  evening  sleep  is  gen- 
erally secured.  The  bromide  habit  is  rarely  formed,  and  is  in 
itself  not  so  seriously  injurious  as  the  chloral  or  opium  habit. 
The  bromides  alone  are  hardly  strong  enough  hypnotics  for 
alcoholic  insomnia  or  the  insomnia  of  insanity.  1  have  found 
them  to  fail  in  the  insomnia  of  the  aged.  Paraldehyde  ranks 
close  to  chloral  in  its  value  as  a  hypnotic.  In  some  persons  it 
disturbs  the  stomach,  but  not  in  all,  and  it  may  be  used  as  a 
hypnotic  for  months  without  its  power  being  impaired.  It  is  a 
disagreeable  drug,  and  there  is  nothing,  so  far  as  I  know,  that 
palliates  its  offensiveness.  '  I  prefer,-  however,  to  prescribe  it  in 
3  i.  doses  poured  upon  a  teaspoonf  ul  of  powdered  sugar.  Doses 
of  3  ss.  are  sufficient  to  cause  sleep  in  many  cases,  and  collapse 
may  be  caused  by  3  ij.  given  to  weak  i^atients.  Urethran,  in 
doses  of  a  scruple  or  more,  is  a  mild  and  agreeable  hj^pnotic,  but 
not  so  certain  as  paraldehyde.  Amylene  hydrate  is  a  hypnotic 
of  similar  i^roperties  to  paraldehyde,  but  less  disagreeable.  It 
is  given  in  doses  of  about  one  drachm.  Lupulin  in  large  doses, 
gr.  X.  to  gr.  XX.,  is  a  good  hypnotic.  Sulphonal  in  doses  of  gr. 
X.  to  gr.  XXX.  given  two  to  four  hours  before  retiring  is  one  of 
the  best  hypnotics.  Chloralamide  is  more  agreeable  and  safer 
than  chloral,  though  it  acts  practically  in  the  same  way.  The 
dose  is  ^  i.  to  ^  ij.  Sonnial,  trional,  tetronal  are  new  drugs 
which  act  well  in  many  cases. 

Among  the  antispasmodics  are  several  drugs  which  occasion- 
ally answer  well  in  the  insonmia  due  to  nervous  irritability.  A 
drachm  of  the  fluid  extract  of  valerian  or  of  spirits  of  lavender, 
for  example,  may  be  prescribed.  In  some  forms  of  insomnia — 
perhaps  b*t  in  those  due  to  fever,  or  pain,  or  some  rheumatic  or 
gouty  trou]3le — antipyrin  in  twenty-grain  doses  acts  well.  It  is 
known  that  in  many  cases  of  mild  types  of  insonmia  a  dose  of 
whiskey,  brandy,  or  beer  will  put  the  patient  to  sleep.  Besides 
drugs,  there  are  many  hygienic  or  mechanical  measures  to  which 
the  physician  may  successfully  resort— listening  to  monotonous 


THE   DISORDERS   OF   SLEEP.  49;i 

noises,  reading  dull  or  heavy  books,  counting,  or  keeping  before 
the  fancy  some  blank  or  wearying  picture — 

"  A  flock  of  sheep  that  leisurely  pass  by 
One  after  one  ;  the  sound  of  rain  and  bees 
Murmuring  ;  the  fall  of  rivers,  winds  and  seas, 
Smooth  fields,  white  sheets  of  water,  and  pure  skies." 

Mechanical  remedies  have  nearly  all  for  their  purpose  tne 
withdrawal  of  the  blood  from  the  brain  to  the  skin  and  abdomi- 
nal viscera.  Hot  foot-baths  or  warm  general  baths,  cold  douches 
down  the  spine,  beating  the  limbs  with  rubber  hammers,  brisk 
exercise,  a  light  meal,  massage,  all  are  at  times  efficient  hypnotics. 
Persons  who  suffer  from  insomnia  should  sleep  in  cold  i-ooms,  the 
head  should  not  be  too  high  nor  very  low,  and  in  most  cases  they 
are  better  v;ithout  late  suppers,  even  though  these  be  light. 
Mental  work  should  be  laid  aside  several  hours  before  retiring, 
and  the  evening  devoted  to  quiet  conversation  and  reading  or 
amusements  that  do  not  actively  excite  the  nerves.  Many  per- 
sons live  in  good  health  though  they  sleep  in  the  day  and  stay 
awake  at  night.  Journalists  and  editors,  whose  work  obliges 
them  to  go  to  bed  in  the  early  morning,  often  continue  for  years 
without  impairment  of  physical  vigor.  Yet  despite  this,  it  is  true 
that  the  best  time  for  sleep  is  at  night,  and  that  the  old  maxim, 
"  early  to  bed,"  is  a  sound  one.  The  human  system  requires  a 
certain  amount  of  sleep  and  should  have  it.  The  industrious 
and  ambitious  often  try  to  train  themselves  to  shorter  hours,  but 
though  they  may  succeed  for  a  time,  nature  will  not  be  cheated 
out  of  her  due  and  health  suffers  in  the  end.  It  is  a  wide-spread 
custom  in  some  countries  to  take  a  short  nap  in  the  day-time,  and 
the  custom  is  a  good  one.  America  has  not  adopted  it,  but 
might  do  so  with  benefit  to  the  health  of  her  brain-working  class. 
Many  from  childhood  up  do  not  get  a  sufficient  amount  of  sleep. 

III.  Perversions  and  Disturbances  of  Sleep.— Sleep  is 
said  to  reach  its  deepest  stage  in  from  one  to  two  hours  after  it 
begins.  There  is  then  after  this  a  gradual  lessening  of  the  depth 
of  sleep.  Probably  there  are  great  variations  in  this  rule,  for 
many  persons  seem  in  soundest  skimber  several  hours  after  fall- 
ing asleep.  But,  at  any  rate,  there  are  slighter  stages  of  sleep  at 
its  inception  and  toward  its  end.  These  are  the  favorite  times 
for  dreams,  and  at  this  period  also  there  develop  the  peculiar 
phenomena  of  sleep-drunkenness. 

Breams^  JSightmare.—W\\en  sleep  is  perfect  an^&  profound, 
dreams  afterward  remembered  do  not  occur.  Dreaming  is,  there- 
fore, a  morbid  symptom,  although  often  of  trivial  significance, 
especially  if  it  occurs  at  about  the  time  of  natural  waking,  when 
slumber  is,  in  its  physiological  course,  passing  into  the  lighter 
stages.     In  sleep,  no  matter  how  light,  the  action  of  the  regulat- 


494  DISEASES   OF  THE   NERVOUS   SYSTEM. 

ing  centre  which  directs  thought,  controls  emotion,  and  exhibits 
itself  in  volition  is  suspended;  the  psychical  mechanism,  if  ex- 
cited to  action  at  all,  works  without  purpose,  like  a  rudderless 
ship  at  sea.  Ideas  and  emotions  succeed  each  other  by  the  laws 
of  association,  but  are  not  properly  correlated,  and  judgment 
and  logical  reasoning  are  gone.  As  a  rule,  dreams  are  made  up 
of  somewhat  ordinary  ideas  and  fancies  incoherently  associated, 
and  shifting  too  rapidly  to  call  up  much  feeling.  When  from 
some  point  in  the  body  painful  sensory  excitations  do  excite 
disagreeable  images,  emotions  of  a  most  violent  kind  may  be 
felt. 

In  the  earlier  stages  of  civilization,  among  i^rimitive  people, 
dreams  were  comparatively  rare.  When  they  did  come  with 
vividness  they  were  regarded  with  importance,  and  often  were 
considered  visitations  of  spirits.  Civilized  man  dream;^  more,  but 
he  has  learned  to  treat  his  fancies  with  corresponding  indiffer- 
ence. The  attempts  of  scientific  men  to  fornmlate  laws  regard- 
ing them  have  been  productive  of  small  results.  Some  diseases, 
however,  produce,  as  a  rule,  dreams  of  a  more  or  less  peculiar 
kind.  Thus  heart  disease  is  accompanied  with  dreams  of  im- 
pending death.  Previous  to  attacks  of  cereb7*al  hemorrhage, 
patients  have  dreamed  of  experiencing  some  frightful  calamity 
or  of  being  cut  in  two.  Intermittent  fever  is  often  announced 
by  persistent  dreams  of  a  terrifying  character.  Hannnond  has 
collected  a  large  number  of  what  he  terms  prodromic  dreams,  all 
going  to  show  that  before  recognizable  signs  of  disease  are  pres- 
ent morbid  dreams  of  various  kinds  may  occur.  Albers  says: 
"  Frightful  dreams  are  signs  of  cerebral  congestion.  Dreams 
about  fire  are,  in  women,  a  sign  of  impending  hemorrhage. 
Dreams  about  blood  and  red  objects  are  signs  of  inflannnatory 
conditions.  Dreams  of  distorted  forms  are  frequently  a  sign  of 
abdominal  obstructions  and  diseases  of  the  liver."" 

Nightmare  is  a  disorder  incident  to  the  hypohypnotic  state, 
or  that  of  incomplete  sleep.  It  is  one  of  those  minor  ills  that  are 
nearly  always  symptomatic  of  an  irritation  in  some  part  of  the 
body.  The  usual  causes  of  it  are  some  digestive  disturbance 
(repletion)  and  cardiac  disease.  Persons  of  a  nervous  temi^era- 
ment  are  more  subject  to  it;  and  there  are  individuals  whom  it 
makes  suffer  all  their  lives.  The  popular  belief  that  sleeping  on 
the  back  favors  it  is,  in  general,  a  correct  one.  When  nightmare 
occurs  in  cai*diac  disease  a  certain  position,  semi-recumbent  or  on 
the  right  side,  must  be  maintained,  or  the  painful  fancies  awaken 
the  patient.  Healthy  people  can  get  sound  sleep  whether  lying 
upon  the  back,  the  side,  or  the  stomach.  But  light  sleepers,  and 
those  with  sensitive  abdominal  viscera,generally  find  that  the  posi- 
tion on  the  right  side  is  the  most  comfortable  and  less  provoca- 


THE   DISORDERS   OF   SLEEP.  495 

tive  of  unpleasant  dreams.  Prolonged  mental  or  physical  strain, 
excitement,  and  worry  predispose  to  nightmare.  Farinaceous 
foods,  excessive  use  of  strong  liquors,  coffee,  and  tobacco,  all 
have  a  similar  tendency,  ^^ightmare  occurs  also  in  anaemia  and 
malaria,  and  it  may,  in  fine,  be  excited  by  morbid  conditions  in 
any  part  of  the  body.  It  sometimes  occurs  about  the  menstrual 
period  in  Avomen.  Its  most  common  feature  is  a  sense  of  suffoca- 
tion or  imxjending  death. 

Pavor  nocturmts,  or  night-terrors,  is  a  sleep  disorder  peculiar 
to  children.  It  is  allied  to  nightmare  on  the  one  hand  and  sleep- 
drunkenness  on  the  other.  It  differs  from  the  former  condition 
in  that  the  child  continues  to  suffer  from  the  distressing  fancies 
for  some  time  after  he  is  awake.  Night-terrors  occur  usually  one 
or  two  hours  after  sleep  has  begun.  The  child  wakes  up  scream- 
ing with  fright,  and  perhaps  runs  about  the  room  or  seeks  its 
parents  for  protection  against  some  imagined  harm.  The  dis- 
order occurs  in  weakly,  anaemic,  nervous,  or  rheumatic  chil- 
dren. It  is  due  sometimes  to  lithsemia,  or,  as  the  older  writers 
put  it,  rheumatism  or  gout  of  the  brain.  Digestive  disturbances, 
worms,  dentition,  hereditary  syphilis,  mental  strain,  fright,  and 
excitement  are  placed  among  the  causes.  It  sometimes  appears 
to  be  a  i^aroxysmal  neurosis  allied  to  epilepsy.  The  disorder  is 
usually  harmless  and  the  prognosis  favorable. 

Somnolentia,  or  sleep-drunkenness  {Schlafentnink),  is  a  condi- 
tion of  incomiDlete  sleep  in  which  a  part  of  the  faculties  are  abnor- 
mally excited  while  the  others  are  buried  in  repose.  It  is  a  kind 
of  acted  nightmare.  The  person  affected  is  incoherent,  excited, 
and  often  violent.  He  experiences  the  delusion  of  some  impend- 
ing danger,  and  while  under  it  acts  of  violence  have  been  com- 
mitted. The  condition  is  one  of  medico-legal  importance,  there- 
fore, and  has  been  discussed  by  writers  on  that  science  (Wharton 
and  Stille).  Minor  degrees  of  it  are  often  noticed  in  children  and 
in  adults  Avho  are  roused  from  a  very  profound  sleep.  It  at 
times  becojnes  a  habit,  and  a  most  annoying  or  dangerous  one. 
The  disorder  in  its  severe  form  is  fortunately  very  rare. 

The  treatment  of  morbid  dreams,  nightmare,  and  pavor  noc- 
turnus  must  be  directed  to  a  removal  of  the  causes.  Tonics,  car- 
diac stimulants,  laxatives,  anti-rheamatics,  attention  to  diet,  are 
called  for  according  to  the  condition  of  the  patient.  Change  in 
surroundings  is  often  necessary.  Among  symptomatic  remedies 
the  bromides  are  the  best,  except  in  lithsemia.  when  alkalies  and 
salicylates  may  prove  more  serviceable.  In  somnolentia  the  j^a- 
tient  should  be  prevented  from  getting  into  too  profound  sleep. 
He  may  be  awakened  once  or  twice  during  the  night,  or  take  a 
nap  in  the  day-time.  The  head  in  sleeping  should  be  raised  high 
and  the  body  not  too  heavily  covered. 


496  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Som7ia)nbiili's?n. — Somnambulism  is  a  condition  similar  to 
hypnotism  or  the  mesmeric  state.  In  it  volition  is  abolished,  and 
the  mind  acts  automatically  under  the  dominance  of  some  siny:le 
idea.  Sig:ht,  hearing,  and  nearly  all  the  avenues  of  sense  are 
closed.  The  sleep-walker  avoids  obstacles  and  performs  ordinai-y 
acts  automatically,  like  an  absent-minded  man,  which  in  reality 
he  is.  All  those  mechanisms  which  have  been  trained  by  con- 
stant repetition  to  act  automatically,  like  that  which  preserves 
equilibrium,  are  active,  and  their  jjowers  may  even  be  height- 
ened, so  that  the  somnambulist  may  walk  along  roofs  or  on  dan- 
gerous roads  and  thread  intricate  passages  without  harm.  The 
automatism  of  the  somnambulist  may  continue  for  hours,  until 
a  journey  has  been  i3erformed  or  a  task  completed.  He  may 
carry  out  with  success  intricate  mathematical  calculations,  write 
a  letter,  or  work  upon  a  picture,  but  he  onh'  follows  along  the 
lines  established  by  constant  iteration  in  his  waking  moments. 
He  can  originate  nothing  new.  He  is  roused  from  his  state  with 
difficulty,  and  when  out  of  it  he  remembers  nothing  of  what  has 
occurred. 

Somnambulism  usually  arises  from  overeating.  Sleeping 
with  the  head  too  low  is  another  cause.  Violent  emotions  act  in- 
directly by  disturbing  digestion.  The  habit  being  once  estab- 
lished, however,  attacks  occur  without  apparent  cause.  The  dis- 
order occurs  oftenest  in  young  people  about  the  age  of  puberty, 
and  it  then  attacks  the  sexes  alike.  Later  in  life  women  are 
more  often  affected.  The  disease  is  fostered  sometimes  at  school 
by  the  attentions  of  the  schoolmates.  In  most  cases  a  condition 
of  morbid  sensitiveness  underlies  it.  The  patients  are  neurotic. 
Hereditary  sonniambulism  has  been  observed.  Its  attacks  have 
alternated  with  those  of  catalepsy.  They  are  likely,  after  a  time, 
to  become  periodical,  occurring  every  week,  fortnight,  or  month. 
The  somnambulic  state  may  come  upon  a  person  in  the  day- 
time. It  is  then  regarded  as  spontaneous  trance,  or  hypnotism. 
It  is  not  the  case,  however,  that  persons  who  are  easily  hypno- 
tized are  usually  somnambulists,  though  the  reverse  may  be  true. 

Sonmambulism  is  a  term  that  should  include  not  only  sleep- 
walking, but  sleep-talking. 

The  treatment  of  somnambulism  is  very  much  like  that  for 
sleep-drunkenness.  The  patient's  surroundings  must  be  inves- 
tigated, and  unfavorable  influences,  such  as  may  occur  at  school 
or  from  injudicious  nurses,  be  removed.  He  shoukl  be  prevented 
from  sleeping  too  soundly,  the  head  should  he  raised,  the  cloth- 
ing light,  the  diet  regulated.  Reiiiedies  like  iron,  quinine,  phos- 
phorus, and  cod-liver  oil  may  be  given.  When  the  patient  is 
discovered  in  the  somnambulistic  state  he  should  not  be  awak- 
ened, or  at  least  not  until  he  is  safely  back  in  bed. 


THE   DISORDERS   OF   SLEEP.  497 

Hypxotism,  Trance,  Mbsmbrism.— Hypnotism  is  a  morbid 
mental  state  artificially  produced  and  characterized  by  (1)  per- 
version or  susi^ension  of  consciousness ;  (2)  abeyance  of  volition ; 
(o)  a  condition  of  suggestibility  leading  the  patient  to  yield 
readily  to  commands  or  external  sense  impressions;  and  (4)  in- 
tense concentration  of  the  mental  faculties  upon  some  idea  or 
feeling. 

The  proportion  of  persons  of  all  ages  found  to  be  hypnotizable 
by  Beannis  was  about  eighteen  or  twenty  per  hundred.  Children 
up  to  the  age  of  fourteen  are  very  susceptible.  After  the  age  of 
fifty-five  susceptibility  lessens.  Men  are  almost  as  easily  affected 
as  women;  but  persons  of  a  docile  mind  and  those  trained  to 
some  degree  of  mental  discipline  and  capacity  for  submission, 
such  as  soldiers  and  artisans,  are  more  sensitive.  In  this  coun- 
try the  percentage  of  hypnotizable  subjects  is  less  than  it  is  in 
Europe.  Hysterical  and  insane  persons  are  not  very  suscejjtible. 
Those  who  have  been  mesmerized  once  are  more  easily  affected 
afterward,  and  may  even  pass  into  the  state  involuntarily. 

Methods. — There  are  two  ways  of  inducing  hypnotism,  the 
fixation  method  and  the  suggestive  method.  The  former  and 
older  plan,  devised  by  Braid,  is  to  make  the  patient  fix  his  eyes 
for  five  to  ten  minutes  on  some  bright  object  at  a  distance  of  six 
to  eight  inches  from  the  eyes  and  a  little  above  the  horizontal 
plane  of  vision.  A  modification  of  this  is  the  fascination  method 
of  Luys,  by  which  the  patient  is  made  to  fix  his  eyes  at  revolving 
mirrors. 

In  the  *'  suggestive  method "  devised  by  Liebault  and  Bern- 
heim  the  subject  is  placed  in  a  chair  in  front  of  the  operator. 
The  operator  then  talks  to  the  subject  in  a  firm  and  confident 
voice,  assuring  him  that  he  will  go  to  sleep  in  a  short  time,  tell- 
ing him  to  make  no  resistance,  that  his  sleeping  will  be  natural, 
that  nothing  will  be  done  to  worry  or  fatigue  him,  that  he  v/ill 
dream  pleasant  dreams,  that  he  will  wake  up  feeling  better ;  then 
that  he  is  feeling  drowsy,  his  eyes  are  heavy,  objects  look  con- 
fused, the  lids  are  falling,  thej^  are  closed— in  a  moment  more  the 
patient  goes  off  to  sleep.  This  requires  some  little  time— five  to 
fifteen  minutes.     It  may  fail  the  first  time  and  succeed  the  second. 

Hypnotic  states  may  be  self-induced  by  rigorously  fixing  the 
attention  upon  some  object.  The  ecstatic  states  of  the  saints 
and  the  nirvana  of  the  Buddhists  are  forms  of  hypnotism;  so 
also  are  the  trance  states  into  which  some  clairvoyants  and  spirit- 
ualistic preachers  place  themselves;  this  same  curious  phenom- 
enon is  at  the  bottom  of  the  so-called  "  mind-healing "  science, 
and  it  enters  into  rational  therapeutics  and  orthodox  religion. 
The  capacity  of  the  human  mind  for  hypnotism  or  semi-hypnotic 
states  is,  therefore,  a  most  curious  and  important  fact. 
32 


498  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Symptoms.— The  person  who  has  been  hypnotized  at  first  sits 
or  hes  quietly  in  the  position  he  had  assumed  during  the  manip- 
ulations of  the  operator.  No  notable  physiological  changes 
occur,  as,  for  example,  in  the  pulse,  respiration,  temperature, 
pupils,  skin,  etc.  Some  increase  in  the  cerebral  blood  supply, 
however,  is  said  to  be  present.  The  patient  will  now  respond 
automatically  to  any  outside  command  or  will  be  dominated  by 
any  idea  which  is  suggested  to  him.  He  will  talk,  or  walk,  or 
run,  or  gesticulate,  assume  expressions  of  fright,  anger,  or  joy, 
entirely  in  accordance  with  the  command  given.  Apart  from 
these  commands  he  is  entirely  dead  to  the  outside  world.  He 
hears,  sees,  smells,  tastes,  and  feels  nothing.  He  can  be  burned, 
cut,  or  injured  without  showing  any  signs  of  feeling.  At  a  sug- 
gestion he  may  be  made  cataleptic,  somnambulic,  or  paralytic. 
This  state  is  termed  somnambulistic  trance.  If  left  to  himself, 
he  gradually  sinks  into  a  deep  sleep,  from  which  he  can  with 
difficulty  be  roused.  After  a  time,  rarely  more  than  one  or  two 
hours,  he  awakes  as  from  ordinary  slumber.  This  latter  state  is 
called  trance-coma,  or  lethargic  hypnotism.  The  attempts  of  the 
Charcot  school  to  divide  hypnotic  phenomena  into  three  forms, 
the  somnambulic,  cataleptic,  and  lethargic,  are  hardly  success- 
ful. Sensitive  subjects  can  be  thrown  at  once  into  lethargy,  cat- 
alepsy, or  somnambulic  states  at  the  comioand  of  the  o^^erator. 

The  phenomena  of  liypnotism  depend  upon  the  wonderful 
sensitiveness  and  quickness  of  the  subject  in  responding  involun- 
tarily, with  all  his  nervous  energy,  to  outside  suggestion.  Dis- 
honest persons  may  learn  the  latter  trick  and  thus  simulate  the 
hypnotic  state.  Travelling  mesmerizers  utilize  such  persons 
largely,  hence  no  confidence  canP  be  placed  in  the  phenomena  ex- 
hibited by  them. 

Besides  the  above  hypnotic  state,  which  I  call  the  major  hyp- 
notism, various  minor  stages  occur.  These  are  produced  by  the 
"  suggestive  method "  of  hypnotizing.  By  this  latter  plan 
patients  are  thrown  into  various  degrees  of  the  hypnotic  state 
from  slight  drowsiness  to  complete  lethargy. 

Patients  naturally  come  out  of  the  mesmeric  state  through 
the  channel  of  deep  sleep  or  lethargy.  Ordinarily  they  are  de- 
hypnotized  by  word  of  command,  or  by  a  pass  of  the  hand,  or  any 
impression  which  the  patient  expects  to  be  used  for  the  purpose. 

Hypnotized  persons  have  been  observed  to  have  a  diminution 
in  the  spinal  reflexes  and  a  muscular  hyperexcitability.  They 
sometimes  show  a  most  extraordinary  exaltation  of  visual,  audi- 
tory, or  other  special  sense. 

Pathology.— The  underlying  changes  of  the  hypnotic  con- 
<lition  are  unknown  and  will  probably  long  remain  so.  Hyp- 
notism is  no  doubt  associated  with  changes  in  the  vascularity  of 


THE   DISORDERS   OF   SLEEP.  499 

different  parts  of  the  brain  and  with  rapid  breaking-down  of 
nerve  tissue.  Animals  constantly  subjected  to  hypnotic  influ- 
ence become  demented  (Hartinf?,  Milne-Edwards). 

The  state  of  major  hypnotism  is  probably  pathological.  It  is 
a  neurosis.  Minor  hypnotic  states  are  but  slightly  removed  from 
the  normal,  and  their  i^roduction  is  not  injurious. 

i>/«^M06'/6'.— As  hypnotic  states  maybe  imitated  and  as  inju- 
ries or  crimes  may  be  done  during  this  state,  it  is  very  important 
to  be  able  accurately  to  distinguish  it.  Since  the  phenomena 
are  all  subjective,  this  is  very  difficult.  Tlfe  methods  of  value  are 
these :  1.  Careful  examination  of  the  general  phenomena  by  experts 
while  the  subject  is  in  the  alleged  hypnotic  state.  2.  Testing  the 
muscular  hyperexcitability  by  percussing  motor  points.  3.  Tests 
of  alleged  aniesthesia  by  sudden  burning,  or  pinching,  or  injur- 
ing the  subject.  4.  Tests  of  the  tetanic  muscular  rigidity  by  the 
revolving  tambour.  In  the  hypnotic  state  the  hand  may  be  ex- 
tended and  held  with  perfect  steadiness,  while  in  conscious  states 
a  tremor  soon  appears.  5.  Tests  with  glasses  and  other  appci- 
ratus  may  be  made  to  determine  alleged  ana^sthesiie  of  the  special 
senses. 

Therapeutics. — The  practice  of  using  major  hyjDnotization  is 
injurious,  tending  to  exhaust  the  nervous  force  and  weaken  the 
will.  It  should  be  done  only  with  the  greatest  care.  Its  utility 
in  therapeutics  I  greatly  doubt.  It  may  relieve  symptoms  in 
the  hj^sterical  for  a  time,  but  it  cannot  be  of  permanent  benefit 
and  is  likely  to  lead  to  actual  harm. 

The  induction  of  minor  hypnotic  states  by  suggestion  is  not 
harmful  if  carefully  and  moderately  employed.  Its  practical  re- 
sults, however,  are  not  great,  and  the  method  is  tedious,  uncer- 
tain, and  sometimes  ridiculous.  It  has  its  value  in  pedagogy, 
among  children,  in  neurasthenia  and  morbid  habits.  The  gen- 
eral popularization  of  hypnotism  by  means  of  mind-cures.  Chris- 
tian science,  etc.,  accomplishes  its  results  at  the  expense  of 
mental  demoralization;  and  faith-healing  institutes  are  more 
pernicious  elements  in  society  than  gin-mills. 

Morbid  Drowsixess. — This  is  a  very  common  symptom, 
which  may  be  due  to  any  one  of  the  following  causes :  1.  Old  age, 
when  there  is  a  weakened  heart  or  diseased  arteries,  with  cerebral 
mal-nutrition.  2.  The  diseased  vascular  conditions  which  precede 
cerebral  hemorrhage.  3.  The  cerebral  mal-nutrition  or  inflam- 
mations occurring  before  or  during  certain  forms  of  insanity.  4. 
Various  toxsemiie,  e.g.,  malarial,  uremic,  choltemic,  and  syphi- 
litic. 5.  Dyspepsia  and  gastric  repletion.  6.  Diabetes.  7.  Obe- 
sity. 8.  Insolation.  9.  Cerebral  anaemia,  and  hyper^emia.  10. 
Exhausting  diseases.  11.  Concussion  of  the  brain.  12.  Climatic 
conditions,  cold,  etc. 


500  DISEASES   OF   THE   NERVOUS   SYSTEM. 

A  very  common  cause  of  drowsiness  is  dyspepsia  attended  with 
some  torpidity  of  tlie  liver,  the  condition  popularly  known  as 
*'  biliousness/'  Another  frequent  cause  is  malarial  infection,  which 
perhaps  acts  indirectly  by  impairing  the  functional  activity  of 
the  liver.  Drowsiness  from  these  causes  oftenest  comes  on  in  the 
afternoon.  An;emia  is  attended  with  drowsiness  during  the  day, 
while  there  is  often  i^somnia  at  night.  Syphilis  is  more  likely 
to  cause  insonniia,  but  in  its  third  stage  somnolent  conditions 
may  be  produced  which  are  of  serious  significance.  Drowsiness 
occurs  froui  the  effect^  of  severe  cold.  It  sometimes  tlevelops 
when  persons  change  their  surroundings,  especially  on  going  to 
the  seashore,  for  low  levels  and  a  high  degree  of  atmospheric 
pressure  seem  to  promote  sleep.  The  drowsy  state  that  some- 
times follows  concussion  of  the  brain  is  a  familiar  phenomenon. 
Some  persons,  no  doubt,  acquire  the  habit  of  drowsiness.  At 
first  the  trouble  may  have  been  induced  by  indigestion,  "  bilious- 
ness,'' or  malarial  infection,  but  it  persists  after  the  cause  is  re- 
moved. Such  persons  can  hardly  sit  through  a  lecture,  a  church 
service,  or  any  exercise  requiring  quiet  and  attention.  As  the 
morbid  drowsiness  here  described  is  only  symptomatic,  its  treat- 
ment need  not  be  discussed.  Such  remedies  as  coca,  coffee,  tea, 
atropia,  glonoin,  do  not  produce  results  equal  to  expectations. 

Morbidly  Beep  ^leep. — Certain  persons,  when  they  sleep,  pass 
into  an  almost  lethargic  slumber.  Persons  who  sleep  in  this  way 
often  sleep  a  longer  time  than  normal.  They  are  awakened  with 
difficulty,  and  then  suffer  with  headache  or  disagreeable  sensa- 
tions throughout  the  day.  The  symptom  may  be  a  prodroma  of 
insanity.  Instances  in  which  persons  retire  at  the  usual  hour, 
but  can  with  great  difficulty  be  roused  in  time  for  the  ordinary 
duties  of  the  day,  are  not  rare.  Some  of  these  are  illustrations 
of  the  vice  of  indolence,  but  in  other  cases  there  is  an  absolute 
need  of  nine,  ten,  or  even  fourteen  hours  of  sleep. 

This  disorder  of  sleep  is  most  liable  to  occur  in  the  young  and 
in  those  of  nervous  temt)erament.  It  often  seems  to  be  a  congen- 
ital condition,  for  which  nothing  can  be  done.  In  other  cases  it 
results  from  over-feeding  and  indolent  habits.  Treatment  is 
much  the  same  as  that  indicated  for  sleep-drunkenness  and  som- 
nambulism. 

o.  P(tr<Kvysm<d  Sleep,  Narcolepsy,  Sleep-Epilepsy. — It  some- 
times happens  that  persons  suffer  from  sudden  attacks  of  uncon- 
querable drowsiness;  they  fall  off  into  slumber  despite  every 
effort  of  the  will.  These  are  more  than  drowsy  sensations,  for 
sleep,  or  a  state  resembling  it,  cannot  be  kept  off.  Some  of  these 
cases  are  of  a  purely  nervous  character,  i.e.,  the  trouble  is  not 
due  to  a  humoral  poison  or  to  organic  disease,  but  to  a  paroxys- 
mal change  in   the  nervous  centres  of  a  vascular  or  chemical 


THE   DISORDERS   OF  SLEEP.  501 

character,  causing  sleep.  It  may  be  that  the  patienr  is  epileptic 
and  the  sleep-seizure  takes  the  place  of  the  ordinary  epileptic 
spasms. 

Cases  of  epileptic  sleep,  or  narcolepsy,  and  allied  forms  are  not 
of  frequent  occurrence.  Females  are  rather  more  often  affected 
than  males,  and  the  susceptible  age  is  from  fifteen  to  forty.  The 
disorder  is  brought  on  sometimes  by  fright,  over-strain,  and 
humoral  poisons  acting  on  a  predisposed  nervous  system. 

The  course  is  chronic  and  relief  is  not  always  obtained.  It 
should  be  remembered  that  syphilis,  malaria,  or  anaemia,  and  in- 
digestion may  be  elements  in  the  trouble  which  are  important, 
if  not  fundamental.     Bromides  in  small  doses  are  often  useful 


ii 

L 

1 

'  ^ 

m 

h 

i 

Fig.  207.— a  Case  op  Catalepsy. 

factors  in  treatment.     Change  of  occupation,  of  mode  of  life,  or 
of  climate  may  be  essential  to  a  cure. 

Catalejjsy,  Trance,  Lethargy. — Most  of  the  so-called  cases  of 
prolonged  sleep,  lasting  for  days  or  weeks,  are  cases  of  sponta- 
neously developed  mesmeric  sleep  in  hysterical  women  or  cases 
of  incipient  insanity  (katatonia  or  stuporous  melancholia).  The 
phenomena  in  these  cases  may  take  the  form  of  catalepsy,  with 
waxy  rigidity  of  the  limbs,  or  lethargy.  In  cataleptic  states  the 
limbs  may  be  placed  in  various  positions  and  will  remain  there  for 
several  minutes  (Fig.  207).  In  lethargy  or  trance  states  the  patient 
may  be  plunged  into  a  deep  and  prolonged  unconsciousness, 
lasting  from  one  day  to  several  years.  These  are  the  "  sleep- 
ing girls ''  of  the  new^spapers.  Others  are  persons  of  a  too 
ready  susceptibility  to  mesmeric  suggestion,  who  get  into  a 
morbid  habit  of  going  into  mesmeric  sleep  spontaneously. 
In  these  states  there  may  be  a  lowering  of  bodily  temperature, 


502  DISEASES   OF   THE  NERVOUS   SYSTEM. 

slowing  of  respiratory  and  heart  action,  and  excessive  sluggish- 
ness oAhe  action  of  the  bowels.  The  patients  can  hear  and  may 
respond  to  suggestions,  but  they  are  apparently  insensible  to 
painful  hupressions  and  do  not  appear  to  smell,  taste,  hear,  or 
see.  The  eyes  are  closed  and  turned  upward,  and  the  pupils  con- 
tracted as  in  normal  sleep.  Many  variations,  however,  occur  in 
the  physiological  phenomena  of  these  states. 

The  duration  of  the  attacks  of  trance  lethargy  is  from  a  few 
hours  to  ten  years.  Ordinarily,  however,  profound  trance  sleep 
lasts  not  more  than  a  few  days,  while  those  cases  in  which  the 
sleep  is  from  mesmeric  suggestion  last  but  a  few  hours. 

The  katatonic  cases  after  a  few  weeks  or  months  gradually 
awake,  become  excited,  and  then  pass  into  a  condition  of  demen- 
tia or  into  catalepsy  again. 

5.  Morbid  Sleep  from  Organic  Disease.— Prolonged  and 
excessive  sleep  occurs  as  the  result  of  syphilis  of  the  brain,  brain 
tumors,  and  the  degenerative  changes  in  old  age  and  insanity. 
Morbid  somnolence  and  stupor  are  not  very  frequent  in  cerebral 
syphilis,  but  are  quite  characteristic.  The  patient  in  some  cases 
lies  or  sits  all  day  in  a  semi-soporous  state;  in  other  cases  he 
walks  about,  but  continually  falls  asleep  at  his  task.  This  state 
of  partial  sleep  may  pass  off  or  end  in  complete  stupor  (Wood). 
It  does  not  necessarily  signify  a  serious  issue,  even  though  it  last 
for  weeks.  Somnolence  or  sleep  is  a  rare  symptom  in  cases  of 
cerebral  tumors  other  than  syphilitic.  Conditions  of  drowsiness 
or  stupor  have  been  noted  especially  in  tumors  of  the  corpora 
quadrigemina  and  the  parietal  lobes  (Putnam- Jacobi). 

Organic  diseases  of  the  brain  tend  to  produce  conditions  of 
mental  weakness,  hebetude,  or  comatose  states,  rather  than  any- 
thing allied  to  sleep. 

The  Sleepixg  Sickxess,  Sleeping  Dropsy,  Maladie  du 
SOMMEIL. — This  is  a  i^eculiar  disorder,  apparently  infectious  in 
character,  which  occurs  among  the  negroes  of  the  western  coast  of 
Africa.  The  disease  has  been  transported  to  other  regions,  but  is 
endemic  only  in  Africa.  It  begins  gradually  with  some  headache 
and  malaise.  Soon  there  is  felt  a  drowsiness  after  meals.  This 
increases  until  the  patient  lies  for  nearly  the  whole  time  in  a 
stupor.  When  awake  he  is  dull  and  apathetic.  There  seems  to 
be  no  fever,  and  the  temperature  may  even  be  subnormal ;  the 
pulse,  too,  is  not  rapid;  the  skin  is  dry,  the  tongue  moist  but 
coated,  the  bowels  regular.  The  eyes  become  congested  and 
prominent.  The  cervical  glands  are  enlarged.  The  disease  ends 
in  coma  and  finally  death.  Recovery  rarely  occurs.  Sometimes 
the  course  of  the  disease  is  more  violent,  and  toward  the  end 
there  are  epileptic  convulsions  and  muscular  tremors.  Autopsies 
have  revealed  no  definite  ^pathological  changes. 


THE   DISORDERS   OF   SLEEP.  503 

Accidents  of  Sleep.— Owing  to  the  fact  that  sleep  is  a  rest- 
ing state  of  the  organism,  and  that  many  of  its  functions  are 
lowered,  or  their  cerel^ral  control  lessened,  peculiar  crises,  or  phy- 
siological and  pathological  disturbances  of  nervous  equilibrium, 
occur.  Attacks  of  gout,  of  asthma,  and  of  pulmonary  hemor- 
rhage are  most  liable  to  occur  during  the  early  morning  hours. 
Deaths  and  suicides  occur  oftener  in  the  forenoon,  but  births 
oftener  at  night.  Epileptic  and  eclamptic  attacks  occur  with 
much  frequency  at  night.  Involuntary  emissions  of  spermatic 
fluid,  orgasmic  crises,  and  incontinence  of  urine  are  among  the 
pathological  incidents  of  sleep. 

Disorders  of  the  Pr.^dormitium.— Sudden  attacks  of 
starting  of  the  whole  body,  shock-like  in  character,  accompanied 
with  peculiar  feelings  in  the  head  or  occiput,  not  infrequently 
attack  persons  as  they  are  dropping  off  to  sleep.  They  are  of 
slight  significance. 


CHAPTER  XXIX. 

CRANIO-CEREBRAL  TOPOGHAPHT. 

The  object  of  eranio-cerebral  topography  is  to  map  out  upon 
the  scalp  the  under!  ymg  fissures,  convolutions,  and  other  parts 
of  the  brain.  As  this  is  for  purposes  of  surgical  operations,  the 
mapping  is  done  upon  the  shaved  aseptic  scalp,  with  a  soft  anilin 
X^encil  dipped  in  strong  carbolic  solution  (1  to  4),  or  with  a  brush 
and  carbolized  tincture  of  iodine.  The  only  instruments  needed 
are  a  steel  tape  measure  and  an  instrument,  of  nickel-plated'soft 
iron.  This  consists  of  a  flat  strip  25  cm.  long  and  1  cm.  wide. 
From  its  middle  there  branches  a  second  strip  10  cm.  long  mak- 
ing an  angle  of  67°  with  the  longer  strip.*  Practically,  the  prin- 
cipal points  to  be  determined  are  the  position  of  the  longitudinal, 
Rolandic,  Sylvian,  and  parieto-occipital  fissures  and  the  lower 
outline  of  the  brain. 

The  measurements  are  based  chiefly  upon  the  known  relations 
of  certain  landmarks  on  the  skull  to  the  parts  beneath.  These 
landmarks  are  the  glabella,  bregma,  lambda,  steiDhanion,  aste- 
rion,  and  pterion,  which  are  points  at  the  junction  of  the  various 
sutures  with  each  other  and  with  certain  ridges  or  protuberances. 
Their  position  is  shown  in  the  cut  (Fig.  208)  except  that  of  the 
glabella  or  prominence  just  above  the  naso-frontal  suture.  The 
inion  is  identical  with  the  occipital  protuberance. 

The  following  rules  are  based  upon  the  observations  of  Heftier, 
Thane,  Reid,  Horsley,  Fraser,  and  myself: 

I.  The  longitudinal  fissure.  This  corresponds  with  the  naso- 
occipital  arc, 

II.  The  fissure  of  Rolando.  Measure  the  distance  from  the 
glabella  to  the  inion ;  find  55. 7  per  cent  of  this  distance,  and  thej 
figures  obtained  will  indicate  the  distance  of  the  upper  end  of  i 
the  fissure  of  Rolando  from  the  glabella.  It  should  be  about  48 
mm.  behind  the  bregma  in  male  adults,  45  mm.  in  women,  30  tOj 
42  mm.  in  infants  and  young  children  respectively. 

The  fissure  runs  downward  and  forward  for  a  distance  of' 
about  10  cm.  measured  on  the  scalp,  the  real  length  being  about 
8.5  cm.     The  fissure  makes  an  angle  of  about  67°  with  the  ante- 

*  Special  iustruments  called  cyrtometers  have  been  devised  by  Wilson  and  Hors- 
ley, but  are  not  necessary. 


CRANIO-CEREBRAL  TOPOGRAPHY. 


505 


rior  part  of  the  longitudinal  fissure.  This  direction  is  determined 
by  the  instrument  above  described  or  by  the  cyrtometer.  The 
lower  third  of  it  is  more  vertical,  and  the  lower  end  is  25  to  30 
mm.  behind  the  coronal  suture.  A  line  from  the  stephanion  to 
the  upper  part  of  the  asterion  should  about  pass  through  it.  The 
fissure  is  shorter  in  children. 

IIT.  The  fissure  of  Sylvius  runs  nearly  horizontally,  and  lies 
either  under  or  a  little  above  the  uppermost  part  of  the  parieto- 
squamous  suture.  This  suture,  the  external  orbital  process,  and 
the  parietal  eminence  are  the  guiding  landmarks  by  help  of 


Fig.  208.— Showing  the  Position  of  the  Bony  Points  on  the  Cranium,  the 
Sutures,  and  the  Principal  Underlying  Fissures,  also  the  Basal  Outline  op 
THE  Brain  (after  Fouillehouse). 


which  the  surgeon  can  often  operate  without  marking  down  lines 
on  the  scalp.  In  children  the  fissure  is  sometimes  higher  and 
more  oblique. 

To  outline  it,  draw  a  vertical  line  from  the  stephanion  to  the 
middle  of  the  zygoma.  Draw  a  horizontal  line  from  the  ex- 
ternal angular  process  to  the  highest  part  of  the  squamous 
suture;  continue  this  back,  gradually  curving  it  up  till  it  reaches 
the  parietal  eminence.  The  junction  of  the  two  lines  will  be  at 
the  beginning  of  the  fissure  of  Sylvius.  The  vertical  line  indi- 
cates nearly  the  position  of  the  ascending  or  vertical  branch  of  the 
fissure,  which  is,  however,  directed  a  little  more  forward,  and  is 
about  2.5  cm.  (1  inch)  in  length.  The  posterior  part  of  the  line 
indicates  the  position   of   the  posterior  branch   of   the  fissure. 


506  DISEASES   OF   THE  NERVOUS   SYSTEM. 

Reid's  method  of  finding  the  fissure  of  Sylvius  is  to  "  draw  a  line 
from  a  point  1|  inches  behind  the  external  angular  process  to 
a  point  f  inch  below  the  parietal  eminence.  The  ascending 
branch  starts  from  a  point  f  inch  back  from  the  anterior  end  of 
this  line,  and  2  inches  (5  cm.)  back  of  the  external  angular  pro- 
cess."' 

IV.  To  outline  the  loarieto-occipital  fissure,  find  the  lambda, 
mark  a  point  3  mm.  anterior  to  it,  draw  a  line  through  this  at 
right  angles  to  the  longitudinal  fissure,  extending  about  2.25  cm. 
(1  inch)  on  each  side  of  the  median  line.  This  marks  the  position 
of  the  fissure.  If  the  lambda  cannot  be  felt,  its  position  may 
be  found  by  measuring  the  naso-occipital  arc  and  taking  22.8 
per  cent  of  it.  This  indicates  the  distance  of  the  lambda  from  the 
inion  or  external  occipital  protuberance.  The  average  distance 
in  male  adults  is  7.42  cm.  {2}  inches).  It  is  greater  in  women  than 
in  men  by  a  little  over  a  millimetre. 

V.  To  outline  the  frontal  lobes :  The  anterior  end  of  the  frontal 
lobes  reaches  to  a  jDoint  determined  by  the  thickness  of  the  frontal 
bone.  This  ranges  from  2  to  8  or  more  mm.  (jV  to  ^  inch).  The 
floor  of  the  anterior  fossa  reaches  in  front  to  a  level  a  little  above 
the  supraorbital  margin  (10  mm.,  f  inch — Heftier).  It  slopes 
down  and  backward,  its  posterior  limit  being  indicated  by  the 
lower  end  of  the  coronal  suture. 

VI.  To  outline  the  temporal  lobe  and  the  lower  border  of 
the  cerebrum :  The  temporal  lobe  is  limited  above  by  the  fissure 
of  Sylvius,  below  by  the  contour  line  of  the  lower  border  of  the 
cerebrum.  This  latter  corresponds  to  a  line  drawn  from  a  point 
slightly  (about  12  mm.)  above  the  zygoma  and  the  external  audi- 
tory meatus  to  the  asterion,  and  continued  on  along  the  superior 
occipital  curve  to  the  inion.  The  anterior  border  of  the  lobe 
corresponds  to  the  posterior  border  of  the  orbital  process  of  the 
malar  bone. 

The  temiDoral  lobe  is  about  4  cm.  (If  inches)  wide  at  the  ex- 
ternal auditory  meatus.  A  trephine,  as  Bergmann  states,  placed 
half  an  inch  above  the  meatus  would  enter  the  lower  part  of 
the  lobe.  The  middle  of  the  lobe  is  in  a  vertical  line  from  the 
posterior  border  of  the  mastoid  i>rocess.  A  line  from  the  upper  end 
of  the  fissure  of  Rolando  to  the  point  of  the  process  Avould  pass 
through  this  important  sensory  area  (Fig.  208;  see  also  p.  351). 

VII.  To  find  the  position  of  the  central  ganglia,  viz.,  corpus 
striatum  and  optic  thalamus,  draw  a  line  from  the  upper  end  of 
the  fissure  of  Rolando  to  the  asterion,  practically  a  vertical  line. 
This  limits  the  optic  thalamus  posteriorly.  A  vertical  line  par- 
allel to  the  first,  a  little  in  front  of  the  beginning  of  the  fissure  of 
Sylvius,  limits  the  corpus  striatum  anteriorly.  A  horizontal  plane 
45  mm.  (If  inches)  below  the  surface  of  the  scalp  at  the  bregma 


CRANIO-CEREBRAL  TOPOGRAPHY. 


507 


Lmits  the  ganglia  superiorly.     The  ganglia  he  about  35  mm.  (1| 
inches)  below  the  superior  convex  surface  of  the  brain  (Per^). 

VIII.  To  reach  the  lateral  ventricles:  A  number  of  routes 
may  be  taken.  The  lateral  is  recommended  by  Keen.  Mark  a 
point  1|  inches  behind  the  external  auditory  meatus  and  1\ 
inches  above  a  base  line  made  by  drawing  a  line  through  the 
lower  border  of  the  orbit  and  the  external  auditory  meatus. 
Trephine  at  this  point  and  plunge  the  director  into  the  brain  in 


Fig.  209.— SaowTiNG  the  Relative  Position  of  the  Fissures  and  Cortical 
Centres  of  the  Brain. 


the  direction  of  a  point  21  to  3  inches  vertically  above  the  oppo- 
site external  meatus.  The  ventricle  lies  at  a  depth  of  2  to  2^ 
inches  (5  to  5.7  cm.). 

Mr.  Alec  Fraser  has  devised  a  way  of  mapping  out  the  fissures 
by  means  of  a  series  of  composite  photographs,  so  taken  as  to 
show  the  relation  of  the  underlying  parts  to  certain  tapes  tacked 
upon  the  skull.     One  of  his  figures  is  reproduced  here  (Fig.  210). 

In  applying  this  method  the  surgeon  tacks  the  tapes  on  the 
shaved  scalp.  Then  looking  at  the  diagram  he  finds  where  the 
point  in  the  brain  is  that  he  wishes  to  reach  and  notes  its  rela- 


508  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tion  to  the  median  lateral  or  circumferential  tapes.  Then  as  the 
circumference  of  the  illustrated  head  is  to  the  circumference  of 
the  living  one,  so  is  the  position  of  the  area  on  the  tapes  in  the 
illustrated  head  to  the  desired  position  of  the  same  area  in  the 
living  one.  The  illustration  is  a  composite  of  several  adult  heads 
varying  in  circumference  from  20^  to  23^  inches. 

The  tapes  are  divided  into  inches  and  half  inches.  The  pri- 
mary tape  is  the  circumferential  passing  horizontally  round  the 
vault  of  the  head  (on  the  shaven  scalp)  from  the  root  of  the  nose 
(glabella)  to  the  maximum  occipital  point,  which  is  about  one  inch 
above  the  inion.  The  tape  which  thus  entirely  surrounds  the 
head  is  divided  into  four  equal  parts.  The  points  where  the 
division  is  made  are  at  the  anterior  and  posterior  poles  and  mid- 
way on  each  lateral  half  of  the  tape.  From  these  lateral  mid- 
points a  tape  is  run  vertically  over  the  top  of  the  head,  and 
other  tapes  are  run  anteriorly  and  posteriorly  half-way  between 
the  point  where  the  transverse  tape  crosses  the  sagittal  suture 
and  the  anterior  and  posterior  poles.  Another  longitudinal  tape 
Is  run  from  the  anterior  to  the  posterior  pole  half-w^ay  between 
the  sagittal  suture  and  the  circumferential  tape. 


INDEX 


Abdomixal  reflex,  30 

Abscess  of  the  brain,  346 

Acrania,  333 

Acroceplialic  skull,  27 
I   Acrodynia,  70,  74 
I    Acromegaly,  485 
[   Acro-neuroses,  85 
I   Actinomycosis  of  the  brain,  391 
,   jEsthesiometer,  35 

Age,  etiological  influences  of,  40 

Ageusia,  14G 

Agoraphobia  in  neurasthenia, 
451 

Agraphia,  333 

Akinesia  algeria,  434 

Alcoholic  paralysis,  70 

Alexia,  330 

Allochiria,  definition  of,  23 

Amaurosis,  108,  111 

Amblyopia,  108,  111 

Amimia,  333 

Ampere,  definition  of,  55 

Amputation  neuroma,  90 

Amyelia,  199 

Amygdalum,  298 

Amyosthenia,  423 

Amyotrophy,     progressive 
spinal,  264 

Analgesia,  definition  of,  20 

Anaemia,  cerebral,  345 

of  the  membranes  of   the 
I  brain,  334 

f        of  the  peripheral  nerves,  64 
spinal,  204 

Anaesthesia,  definition  of,  20 
hysterical,  419,  429 


Ansesthesia,  trigeminal,  131 
visual,  in  hysteria,  420 

Angio-ataxia,  definition  of,  23 

Angioma  of  the  brain,  393 

Angio-neurosis,  definition  of,  23 

Angio-neurotic  cedema,  487 

Angio-paralysis,  definition  of,  33 

Angio-spasm,  definition  of,  22 

Anencephaly,  333 

Aneurisms,  intracranial,  395 

Anidrosis,  definition  of,  23 

Ankle  clonus,  31,  34 

Anode,  58 

Anosmia,  107 

Ansa  lenticularis,  299 

Anthropophobia   in  neuras- 
thenia, 452 

Aphasia,  330 

table  of  forms'of,  332 

Aphemia,  331 

Aphthongia,  148 

Apoplexy,  cerebral,  353 
spinal,  200 

Apraxia,  331 

Arachnoid,  spinal,  180 

Arbor  vitse  of  the  cerebellum, 
303 

Arcades,  interfascicular,  9 

Argyll-Robertson  pupil,  34, 117, 
236 

Arm,  paralyses  of  the,  160 

Arteries  of  the  brain  and  its 
membranes,  313 
of  the  spinal  cord,  192 

Arthropathies  of  locomotor 
ataxia,  237 


i 


510 


INDEX. 


Associative    functions    of    the 

brain,  321 
Asthenopia,  definition  of,  108 

muscular,  118 
Ataxia,  definition  of,  21 
family,  251 
Friedreich's,  251 
generic,  251 

locomotor,  231.     See  Loco- 
motor ataxia 
progressive  spastic,  249 
testing  for,  38 
Ataxiagraph,  38 
Ataxic  paraplegia,  hereditary, 

255 
Athetosis,  19 

Atrophia  musculorum  lipoma- 
tosis, 270 
Atrophy,  arthritic  muscular,  275 
of  tiie  brain,  379 
progressive  muscular,  261, 

2b^4 
progressive     muscular,     of 
the  leg  type,  268 
Auditory  nerve,  anatomy  a.nd 
physiology  of  the,  100 
diseases  of  the,  138 
Aura,  epileptic,  407 
Axis  cylinder*  5 

Axis-cylinder  processes  of  nerve 
cells,  2 

Baillarger,  stripe  of,  297 
Ballet-dancers'  cramp,  475 
Bar  sesthesiometer,  36 
Basedow's  disease,  463 
Baths,  forms  of,  49 
Batteries,  varieties  of,  55 
Bell's  palsy,  134 
Beri-beri,  70,  74 
Bilateral  representation,  318 
Birth  palsies,  369 
Blepharospasm,  184 
Blood  supply  of  nerves,  8 

of  the  brain  and  its  mem- 
branes, 312 


Blood  supply  of  the  spinal  cord, 

192 
Brachial  paralyses,  160 
Brachial  plexus,    arrangement 
of  the,  158 
diseases  of  the,  159 
Brachycephalic  skull,  26 
Brain,  abscess  of  the,  346 
actinomycosis  of  the,  391 
acute     softening    of     the, 

862 
anaemia  of  the,  345 
anatomy  of  the,  290 
aneurisms  in  the,  395 
angioma  of  the,  392 
architecture  of  the,  307 
associative  functions  of  the, 

321 
atrophy  of  the,  379 
blood  supply  of  the,  312 
cancer  of  the,  892 
cutting  the,  328 
degeneration  of  the,  373 
diagnosis  between  hemor- 
rhage and  acute  soften- 
ing of  the,  363 
diseases     of    the,     general 

symptoms  of,  829 
embolism  of  the,  362 
enchondroma  of  the,  392 
fibroma  of  the,  392 
functions  of  the,  317 
glioma  of  the,  391 
gumma  of  the,  390 
hemorrhage  in  the,  353 
hypersemia  of  the,  344 
hj^pertrophy  of  the,  379 
inflanunation  of  the,  346 
latent  regions  of  the,  324 
lipoma  of  the,  893 
localization,  317 
localization    of    tumors    of 

the,  384 
malformations  of  the,  333 
membranes  of  the,  diseases 
of,  334 


INDEX. 


511 


Brain,  membranes  of  the,  func- 
tions of,  312 

motor  area  of  the,  317 

osteoma  of  the,  392 

parasitic  growths  of  the,  392 

preserving  the,  328 

red  softening  of  the,  349 

relation  of  the  different 
parts  of  the  spinal  cord  to 
the,  180 

sarcoma  of  the,  391 

sinuses  of  the,  316 

sixteen  ganglionic  deposits 
of  the,  292 

softening  of  the,  349,  362 

syphilis  of  the,  397 

syphiloma  of  the,  390 

thrombosis  of  the,  362 

tracts  of  the,  305 

tumors  of  the,  381 

weight  of  the,  325 
Brauch-Romberg  symptom,  38 
Brown-Sequard  paralysis,  278 
Bulbar  myelitis,  acute,  352 

paralysis,  progressive,  262 
Burdach, column  of,  185, 186, 188 

Caisson  disease,  202 
Cancer  of  the  brain,  392 
Capsule,  internal,  306 
Caput  obstipum,  148 
Catalepsy,  501 
Cathode,  58 

Cavities  in  the  spinal  cord,  280 
Cells,  angular,  of  Lewis,  296 

Deiter's,  8 

ganglion,  1 

granule,  of  Lewis,  296 

nerve,  1 

of  the  cortex  cerebelli,  304 

of  the  cortex  cerebri,  296 

of  the  spinal  cord,  183 

Purkinje,  304 

spider,  8 

spider,  of  the  cortex  cerebri, 
296 


Centres,  cerebral,  317 

spinal  cord,  188,  190 
Centrum  ovale,  physiology  of 

the,  321 
Cephalalgia,  121 
Cerebellum,    anatomy   of   the, 
303 
physiology  of  the,  322 
Cerebro-spinal  meningitis,  epi- 
demic, 338 
Cerebrum,  anatomy  of  the,  290 
Cervical  nerves,  diseases  of  the, 

153 
Charcot-Marie  type  of  progres- 
sive   hereditary  muscular 
atrophy,  268 
Cltildren,    cerebral   palsies    of, 

365 
Choked  disc,  109 
Chorea,  436 

dancing,  441 
electric,  441 
habit,  441 
hereditary,  441 
Huntington's,  441 
insaniens,  437 
maniacal,  437 
of  adult  life,  438 
of  the  larynx,  so-called,  431 
paralytic,  438 
procursive,  441 
senile,  438 
Sydenham's,  436 
Choreic  movements,  18 
Cigarmakers'  cramp,  475 
Civilization,    etiological    influ- 
ences of,  41 
Clarionet  players'  cramp,  474 
Clark's  column,  183,  189 
Claustrophobia    in  neurasthe- 
nia, 451 
Claustrum,  298 

Climate,  etiological  influences 
of,  41 
therapeutic  uses  of,  52 
Clonus,  ankle,  31,  34 


51; 


INDEX. 


Coccvgodynia,  177 
Collaterals  of  a  nerve  fibre,  2 
Columns  of  the  spinal  cord,  184, 

188 
Compression  myelitis,  205,  217 
Conductors,  relative   value  of, 

54 
Conjugate  deviation  of  the 

eyes,  114 
Contractures,  19 

hysterical,  424,  429 
Convolutions  of  the  brain,  292 

microscopic  anatomy  of  the, 
296 
Convulsions,  18 

epileptic,  405,  429 

hysterical,  418,  426,  429     • 

reflex  epileptiform,  404 
Convulsive  tremor,  432 
Coprolalia,  431 

Cord,  spinal,  see  Spinal  cord 
Corpora  quadrigemina,  300 

physiology  of  the,  322 
Corpora  striata,  298 

physiology  of  the,  321 
Corpus  callosum,  i^hysiology  of 

the,  321 
Cortex  cerebelli,  303 

cerebri,  292 
Cramp.  18 

ballet-dancers',  475 

cigarmakers',  475 

clarionet-plaj'ers',  474 

musicians',  474 

photographers',  475 

telegraphers',  474 

watchmakers',  475 

writers',  468 
Cranial  measurements,  table  of, 
25 

nerves,  anatomy  and  phy- 
siology of  the,  92 

nerves,  diseases  of  the,  107 

reflexes,  30 
Cranio-cerebral  topography, 
505 


Cranium,  dimensions  and  shape 

of,  26 
Cremasteric  reflex,  29 
Crises  in  locomotor  ataxia,  239 

neurasthenic,  448 
Current  strength,  definition  of, 

54 
Cyclopia,  333 
Cycloplegia,  116 
Cycling,  value  of,  49 

Deafxess,  nervous,  138 
Degenerations,  44 

diseases  in  which  the  reac- 
tions of,  may  be  expected 
62 
marks  of,  24 
neuritic,  79 
of  brain  tissue,  373 
of  nerves,  65 

of  the  sjjinal  cord,  second- 
ary, 259 
testing  for  reactions  of,  60 
Degenerative    diseases   of    the 

spinal  cord,  229 
Deiter  s  cells,  8 
Delayed  sensation,  37 
Deviation,     conjfigate,    defini- 
tion of,  114 
Diagnosis,  electro-,  60 

of  nervous  diseases,  23 
Diaphragm,    paralysis  of    the, 

15.") 
Diatheses,  etiological  influence 

of,  41 
Diathesis,  contractural,  424 
Diet  for  brain- workers,  47 
Digiti  mortui,  85 
Diplegia,  definition  of,  19 
in  childhood,  365,  369 
Diplopia,  113 
Divers'  paralysis,  202 
Dizziness,  141 
Dolichocephalic  skull,  26 
Dorsal  nerves,  diseases  of  the, 
168 


INDEX. 


513 


Double  sensations,  37 

Drivers'  spasm,  474 

Duchenne-Aran's  disease,  264 

Duchenne,  subacute  spinal 
jjaralysis  of,  226 

Dura  mater,   inflammation  of 
the,  335 
spinal,  180 

Dynamometer,  27 

Dyscesthesia,  definition  of,  21 

Dystrophies,  progressive  mus- 
cular, 261,  269 

ECHOKIXESIS,  431 

Echolalia,  431 

Eclampsia,  18.  See  Convulsions 

nutans,  151 
Elbow  jerk,  33 
Electric  irritability,  alterations 

in,  60 
Electrical   currents  in  nerves, 

13 
Electricity,  definitions  of  tech- 
nical terms,  53 

methods  of  application,  58 

therapeutic  uses  of,  53 
Electrization,  58 

motor  points  for,  59 
Electrodes,  57 
Electro-diagnosis,  60 
Electromotive  force,  definition 

of,  54 
Electrotonus,  14 
Embolism  of  the  brain,  362 
Encephalitis,  346 

acute  exudative,  352 

acute  suppurative,  346 

chronic,  353 

primary,  of  Friedmann,  352 
Enchondroma  of  the  brain,  392 
End-brush  of  a  nerve  fibre,  2 
End  organs  of  nerves,  12 
Endoneurium,  4 
Enteroptosis,  450 
Epigastric  refiex,  30 
Epilepsy,  403 

33 


Epilepsy,  diagnosis,  410 
etiology,  404 
hystero-,  426 
Jacksonian,  404,  407 
laryngeal,  144 
mental  condition  in,  408 
pathology,  409 
physical  condition  in,  408 
physiology,  410 
prognosis,  411 
symptoms,  405 
treatment,  411 
Epineurium,  4 

Erb,  chronic  atrophic  paralysis 
of,  326 
juvenile   form    of    pseudo- 
muscular       hypertrophy 
of,  270 
Erb's  palsy,  161 
Erector-spinse  reflex,  30 
Erythromelalgia,  87,  177 
Etiological  table  of  peripheral 

nervous  diseases,  178 
Etiology  of  nervous  diseases,  40 
Examination    of    patients, 

methods  of,  23 
Exercise,  prophylactic  value  of, 

48 
Exhaustion,  spinal,  288 
Exophthalmic  goitre,  462 
Eye,  anatomy  and  physiology 
of  the  motor  nerves,  95 
diseases    of    the    motor 

nerves,  113 
muscular  asthenopia  or  in- 
sufficiencies of  the,  118 
spasmodic  diseases  of  the 
nmscles  of  the,  120 

Facial  nerve,  anatomy  and 
physiology  of  the,  100 
diseases  of  the,  132 
Farad ic  current,  testing  by  the, 
61 
electrical  batteries,  56 
Feet,  pains  in  the,  87 


5U 


INDEX, 


Fever,  hysterical,  426 
Fibres,  association,  of  the 
brain,  297,  306 
connecting    different    gan- 

gha  of  the  brain,  306 
nerve,  medullated  and  non- 

medullated,  7 
nerve,    a    prolongation    of 

nerve-cell  processes,  2 
nerve,  structure  of  the,  4 
of  the  cortex,  297 
projection,  of  the  brain,  306 
Fibrillary  tremor,  18 
Fibroma  of  the  brain,  392 
Fissures,  cerebral,  292 
Flute-players'  spasm,  474 
Formula  for  applying  electric- 
ity, 58 
FothergilFs  neuralgia,  130 
Friedmann,  primary  encepha- 
litis of,  352 
Friedreich's  ataxia,  251 
Functional    nervous    diseases, 
403 

Galyaxic  current,  testing  by 
the,  61 
electrical  batteries,  57 
Ganglion  cells,  1 

habenulse,  300 
Gangrene,  symmetrical  angio- 
neurotic, 85 
Gedvelst,  network  of,  6 
Geniculate  bodies,  300 
Gerlier's  disease,  144 
Giddiness,  141 
Glioma  of  the  brain,  391 
Gliosis,  46 

Globus  pallidus,  298 
Glosso-labio-laryngeal    paraly- 
sis, 262 
Glosso-pharyngeal  nerve,  anat- 
omy and    physiology  of 
the,  101 
diseases  of  the,  146 
Glossoplegia,  148 


Grand  mal,  404 
Graves'  disease,  462 
Gray  matter,  five  principal  de- 
posits of,  10 
Goitre,  exophthalmic,  462 
Goll,  column  of,  185,  188 
Gout,  nervous,  450 
Gowers,  column  of,  185 
Gumma  of  the  brain,  390 

H.^MATOMYELIA,  201 

Hasmidrosis,  definition  of,  22 

Habit  chorea,  441 

Habits,  etiological  influence  of, 

41 
Hands,  numb,  84 
Headache,  121 
Hearing,    primary    centre    for, 

320 
Hemiansesthesia,  hysterical,  419 
Hemianopsia,  112 

definition  of,  108 
Hemiatrophy,  progressive  lin- 
gual, 148 
Hemicrania,  125 
Hemiopia,  definition  of,  108 
Hemiplegia,  330,  353,  356 

definition  of,  19 

in  childhood,  365 
Hemorrhage,  cerebral,  353 

spinal,  200 
Heredity,  etiological  influences 

of,  41 
Herpes  zoster,  170 
Heterophoria,  118 

spinal,  199 
'Hiccough,  155 
Huntington's  chorea,  441 
Hydatids  of  the  brain,  392 
Hydrencephalocele,  334 
Hydrocephalus,  acute,  340 

chronic,  341 
Hydromyelia,  280 
Hydrorachis  externa,  198 

interna,  198 
Hydrotherapy,  49 


INDEX. 


515 


Hygiene,  47 
Hyperacusis,  145 
Hyperiemia,  cerebral,  344 

of   the  membranes  of  the 
brain,  334 

of  the  peripheral  nerves,  G4 

spinal,  203 
Hyperesthesia,  auditory,  145 

definition  of,  21 

hysterical,  421 

retinal  or  ocular,  111 
Hyperalgesia,  definition  of,  21 
Hypercyalgesia,  definition  of,  37 
Hyperidrosis,  definition  of,  22 
Hyperosmia,  107 
Hyperplasia  of  nerve  trunks,  89 
Hyperthermalgesia,    definition 

of,  37 
Hypertrophy  of  the  brain,  379 

pseudo-muscular,  270 
Hypnotism,  497 

Hypoglossal     nerve,    anatomy 
and  physiology  of  the,  104 

nerve,  diseases  of  the,  147 
Hysteria,  410 

amyosthenia  in,  423 

critical  symptoms  of,  418 

diagnosis,  428 

etiology,  41G 

interjoaroxysmal  symptoms 
of,  419 

major,  418 

minor,  417 

motor  symptoms  of,  422 

IDathology,  428 

permanent  stigmata  of,  419 

prognosis,  429 

sensory  symptoms  of,  419 

symptoms,  417 

treatment,  430 

visceral  symptoms  of,  425 
Hystero-epilepsy,  426 

Ignipedites,  70,  74 
Impulses,  rate  of  travel  of,  13 
Inco-ordination,  testing  for,  38 


Infantile  polioencephalitis,  352 
spinal  paralysis,  220 

Infections,     etiological     influ- 
ences of,  42 

Inflammations,  43 
of  nerves,  68 

Insomnia,  490 

Insufficiencies,     muscular,     of 
the  eye,  118 

Insulators,  relative  value  of,  54 

Intention  tremor,  18 

Iridoplegia,  116 

Irritability,    electrical,    altera- 
tions in,  GO 

Irritation,  sj^inal,  286 

Jacksonian  epilepsy,  404,  407 
Jaw  reflex,  33 
"Jumpers,'^  431 

Knee  jerk,  31 

Labile  electrode,  58 
Laryngeal  syncope,  or  vertigo, 

or  epilepsy,  144 
Larynx,   chorea    of  the,  so- 
called,  431 
Latah,  431 
Lead  palsy,  164 
Leg,  peripheral  palsies  of  the, 

173 
Lenticular  loop,  299 
Leptomeningitis,  335 

acute  simple,  335 

spinal,  206 
Lethargy,  501 
Lid  reflex,  30 
Light  reflex,  33 

Lingual  hemiatrophy,  progres- 
sive, 148 

paralysis,  148 

spasms,  147 
Lipoma  of  the  brain,  392 
Lissauer,  column  of,  185 
Lithsemia,  450 
Lobes,  cerebral,  294 


516 


INDEX. 


Localization,  cerebral,  317 

of  brain  tumors,  384 

spinal,  190 
Lock-jaAV,  132,  443 
Locomotor  ataxia,  231 

arthropathies  of,  237 

cerebral  symptoms  in,  240 

complications  of,  241 

course  of,  241 

crises  in,  239 

diagnosis  of,  246 

disorders  of  hearing  in,  236 

etiology,  231 

eye-symptoms  in,  235 

forms  of,  231 

gait  in,  233 

in  children,  248 

muscular  atrophies  in,  240 

optic  atrophy  in,  235 

pathological  anatomy  and 
pathology  of,  241 

prognosis  of,  246 

reflexes  in,  233 

stages  of,  232 

symptoms,  232 

treatment  of,  246 
Lumbar  nerves,  diseases  of  the, 

170 
Luys'  body,  302 

MALFORMATIO^'S  of  the  brain, 

333 
Massage,  52 
Mastodynia,  169 
Masturbation,  458 
Medulla  oblongata,  physiology 

of  the,  324 
Medullary  sheath,  5 
Membranes  of  the  brain,  anae- 
mia of  the.  334 
of  the  brain,  blood  supply 

of  the,  313 
of  the  brain,  diseases  of  the, 

334 
of  the  brain,  functions  of 
the,  312 


Membranes  of  the  brain,  hyper- 
semia  of  the,  334 
of  the  brain,  malformations 

of  the,  333 
of  the  brain,  symptoms  of 

diseases  of  the,  329 
of  the  spinal  cord,  180 
Memories,  centres  for,  320 
Meniere's  disease,  141 
Meninges,  cerebral,   see  Mem- 
branes of  the  brain 
spinal,  180 
Meningitis,    epidemic    cerebro- 
spinal, 338 
spinal,  205 
tubercular,  340 
Meningocele,  cerebral,  334 

spinal,  198 
Meningo-myelitis,  208 
Meningo-myelocele,  spinal,  198 
Mesmerism,  497 
Mesocephalic  skull,  26 
Meynert's  bundle,  306 
Micromyely,  199 
Migraine,  125 
Milkers'  spasm,  475 
MilliamiDeremeter,  55 
Mimic  tic,  132 
Mind -blindness,  331 
Mogophonia   (fiute-pl ay ers' 

spasm),  474 
Monoplegia,  hysterical,  422 
Morton's  neuralgia,  88 
Morvan's  disease,  79 
Motility,   symptoms    of    disor- 
dered, 27 
Motor,  area  of  the  brain,  317 
points  for  electrization,  dia- 
gram showing  the,  59 
Movements,  choreic,  18 

forced  and  associated,  19 
Multiple  neuritis,  70.    See  Poly- 
neuritis 
Muscles,  centres  for  movements 

of  the,  317 
Muscular  anaesthesia,  38 


INDEX. 


517 


Muscular    atrophies   and   dys- 
trophies, 2G1,  269,  276 

atrophy,  arthritic,  275 

atrophy,  proj^ressive,  264 

atrophy,  progressive  hered- 
itary, of  the  leg  type,  268 

sensibility,  testing  the,  B7 
Musicians'  cramp,  474 
Mydriasis,  116 
Myelin  sheath,  5 
Myelitis,  acute,  210 

acute  bulbar,  352 

central,  218 

chronic,  216 

compression,  205,  217 

disseminated,  211,  216 

forms  of,  210 

periependymal,  218 

transverse,  210,  216 
Myoclonus  multiplex,  432 
Myoidema,  29 
Myosis,  117 
Myospasia,  432 
Myotonia  congenita,  433 
Myriachit,  431 

Mysophobia    in    neurasthenia, 
451 

Narcolepsy,  500 
Neck  imins,  157 

paralysis  of  the  muscles  of 
the,  152,  155 
Necrosis,    perforating,    of    the 

cord,  214 
Nerve  roots,  spinal,  180,  186 
Nerves,  afferent  and  efferent,  11 
ansemia  of,  64 
auditory,   anatomy    and 

physiology  of  the,  100 
auditory,    diseases  of    the, 

138 
cervical,  diseases  of  the,  153 
cranial,  anatomy  and  phy- 
siology of  the,  92 
cranial,  diseases  of  the,  107 
degeneration  of,  05 


Nerves,  dorsal,  diseases  of  the, 
168 

end  organs  of,  12 

facial,  anatomy  and  physi- 
ology of  the,  100 

facial,  diseases  of  the,  133 

glosso-pharyngeal,  a  n  a  t  - 
omy  and  physiology  of 
the,  101 

glosso-pharyngeal,  diseases 
of  the,  146 

hypersemia  of,  64 

hyperplasia  or  hypertrophy 
of,  89 

hypoglossal,  anatomy  and 
physiology  of  the,  104 

hypoglossal,  diseases  of  the, 
147 

inflammation  of,  68 

inter-central  or  commissu- 
ral, 12 

lumbar,  diseases  of  the,  170 

motor,  of  the  eye,  anatomy 
and  physiology  of,  95 

motor,  of  the  eye,  diseases 
of,  113 

olfactory,  anatomy  and 
physiology  of  the,  92 

olfactory,  diseases  of  the, 
107 

optic,  anatomy  and  physi- 
ology of  the,  94 

optic,  diseases  of  the,  108 

peripheral,  functional  dis- 
orders of  the,  80 

peripheral,  relation  of  the 
different  parts  of  the  spi- 
nal cord  to  the,  186 

peripheral,  table  of  diseases 
of,  178 

phrenic,  paralysis  of  the,  155 

pneumogastric  or  vagus, 
anatomy  and  physiology 
of  the,  102 

pneumogastric  or  vagus, 
diseases  of  the,  147 


518 


INDEX. 


Nerves,  regeneration  of,  68 

sacral,  diseases  of  the,  173 

spinal  accessory,  anatomy 
and  physiology  of  the,  103 

spinal  accessory,  diseases  of 
the,  147,  148 

spinal,  diseases  of  the,  513 

structure  of,  1,  4 

syphilis  of,  398 

trigeminal,  anatomy  and 
physiology  of  the,  98 

trigeminal,  diseases  of  the, 
120 

tumors  of,  89 
Nervous    diseases,    functional, 
403 

diseases,  methods  of  study- 
ing, 15 

exhaustion,  44G 

system,  anatomy  of  the,  1 

system,  general  arrange- 
ment and  functions  of 
the,  10 

system,  mechanisms  of  the, 
13 

tissue,  chemistry  of,  14 
Neuralgia,  81 

cervico-brachial,  166 

cervico-occipital,  157 

congestive,  of  the  feet,  87 

digital,  166 

epileptiform,  130 

Fothergiirs,  130 

hysterical,  421 

intercostal,  168 

mammary,  169 

Morton's,  88 

of  the  lumbar  nerves,  172 

plantar,  177 

red,  of  the  feet,  87 

sciatic,  174 

trigeminal,  128- 
Neurasthenia,  446 

course  and  duration,  453 

climacteric,  452 

degenerative,  451 


{ 


Neurasthenia,  diagnosis,  454 

etiology,  446 

in  adolescence,  451 

in  adult  life,  452 

modified  types  of,  451 

pathology,  453 

primary,  451 

prognosis,  455  ■ 

sexual,  451  * 

spinal,  288 

symptoms,  447 

treatment,  455 
Neurilemma,  6 
Neuritic  degeneration,  79 

type  of  syringo-myelia,  79 
Neuritis,  68 

complicated  forms  of,  79 

dermatitic  intercostal,  170 

migrating,  168 

multiple,  70.     See  Polyneu- 
ritis 

l^lantar,  177 

retrobulbar  optic,  109 

sciatic,  174 

symmetrical     spontaneous 
ulnar,  166 
Neuro-fibromata,  plexiform,  89 
Neuroglia,  8 

Neurology,  definition  of,  16 
Neuromata,  89  fl 

on  the  roots  of  the  cranial       ^ 
nerves,  392 
Neurons,  1 
Neuro-retinitis,  108 
Neuroses,  aero-,  85 

degenerative,  403 

different  forms  of,  16 

of    mixed    origin  affecting 
the  extremities,  85 

parses  thesic,  84 

professional    and    occupa 
tion,  468 

sensory,  81 

sexual,  457 

traumatic,  460 
Nictitating  spasm,  134 


I 


INDEX. 


519 


Nightmare,  494 

Nodding  spasm,  151 

Nodes  of  Ranvier,  5 

Nucleus,  caudate,  298 
fastigium,  303 
lenticular,  298 
red,  of  the  brain,  302 
red,  physiology  of  the,  322 

Numb  hands,  84 

Numbness,  waking,  80 

Nystagmus,  120 


Occupation,    muscular    atro- 
phies from,  276 
Qildema,  angio-neurotic,  487 
blue,  of  hysteria,  426 
circumscribed,  487 
Ohm,  definition  of,  54 
Olfactory  nerve,  anatomy  and 
physiology  of,  92 
nerve,  diseases  of  the,  107 
Olivary  bodies,  physiology  of 

the,  324 
Ophthalmoplegia,  114 

progressive,  117 
Optic  atrophy,  110 

atrophy    in    locomotor 

ataxia,  235 
nerve,  anatomy  and  physi- 
ology of  the,  94 
nerve,  diseases  of  the,  108 
Orthophoria,  118 
Oscillating  spasm,  151 
Osteoma  of  the  brain,  392 
Oxycephalic  skull,  27 

Pachymeningitis  externa,  335 

spinal,  205 
Pain  palsy,  434 

sense,  testing  the,  37 
Pains  in  the  feet,  87 

transferred,  diagram  show- 
ing the  location  of-,  82 
Palmar  reflex,  30 
Palsy,  see  Paralysis 


Papillitis    and   neuro-retinitis, 

108 
Parsesthesia,  84 

definition  of,  21 

trigeminal,  131 
Paradoxical  contraction,  33 
Parageusia,  147 
Paralysis,  acoustic,  138 

acute  atrophic,  220 

acute  curable  atrophic,  225 

agitans,  478 

alcoholic,  70 

analgesic,  with  whitlow,  79 

Brown-Sequard,  278 

cerebral,  in  children,  365 

chronic  atrophic,   of    Erb, 
226 

compression,  164 

crutch,  165 

definition  of,  19 

divers',  202 

Erb's,  161 

facial,  134 

from    intracranial    hemor- 
rhage, 355 

glosso-labio-laryngeal,  262 

hereditary  ataxic,  255 

hypertonic,  257 

hysterical,  422,  429 

infantile  spinal,  220 

lingual,  148 

night,  80 

of  the  brachial  nerves,  160 

of  the  cervical  muscles,  152,. 
155 

of  the  circumflex  nerve,  163 

of  the  diaj)hragm,  155 

of  the  iris,  116 

of  the  lumbar  nerves,  170  •• 

of  the  median  nerve,  165 

of  the  motor  nerves  of  the 
eye,  114 

of  the  musculo-spiral  nerve» 
164 

of  the  oculo-motorius,  114 

of  the  phrenic  nerve,  155 


520 


INDEX. 


Paralysis  of  the  posterior  tho- 
racic nerve,  163 

of  the  suprascaiDular  nerve, 
lU 

of  the  ulnar  nerve,  166 

painful,  4;^4 

peripheral  facial,  134 

peripheral,  of  the  leg.  173 

progressive  bulbar,  262 

recumbent.  80 

spinal  spastic.  2-57 

subacute    spinal,     of    Du- 
chenne,  226 
Paralyzing  vertigo,  144 
Paramyoclonus  multiplex,  432 
Paramyotonia,  congenital.  434 
Paraphasia,  332 
Parai^legia,  ataxic.  249 

definition  of,  19 

hereditary  ataxic,  255 

in  childhood.  365 

senile,  226 

spastic,  257 

spastic  cerebral,    of   child- 
hood. 369 
Paresis,  definition  of,  19 
Paridrosis,  definition  of,  22 
Parkinson's  disease,  478 
Patellar  reflex,  31 
Patholog\',  general,  of  nervous 

diseases.  43 
Pathophobia  in  neurasthenia. 

452 
Pavor  nocturnus,  495 
Pedometer,  2^ 
Perineurium,  4 
Peripheral  nervous  system, 

general  diseases  of  the.  64 
Petit  mal.  404,  406 
Photographers'  cramp.  475 
Phrenic  nerve,  paralysis  of  the, 

155 
Physiognomy,  24 
Pia  mater,  inflammation  of  the, 
335 

mater,  spinal  180 


Pianists"  cramp.  474 
Plagiocephahc  skull.  27 
Plantar  neuralgia.  177 

reflex.  29 
Pneumogastric  nerve,  anatomy 
and  physiology  of  the.  103 

nerve,  diseases  of  the.  147 
Podalgia,  87 
Poisons,   etiological  influences 

of.  42 
Policeman's  disease,  83 
Polioencephalitis.  352 
Poliomyelitis,    acute    anterior. 
220 

chronic  anterior.  224 
Poly^esthesia.  37 
Polyneuritis,  70 

acute  pernicious.  75 

diagnosis,  77 

endemic     and     epidemic 
types,  74 

etiology,  70 

malarial,  75 

onset.  72 

pathology,  75 

prodromas,  72 

prognosis,  78 

symptoms,  73 

treatment.  78 
Pons  varolii,  nuclei  of  the.  302 

varolii,  physiology  of  the. 
323 
Porencephaly.  333.  367 
Potential,  difl'erence  in.  53 
Prtedormitium,  5i)3 
Pressure'  sense,  testing  the.  36 
Projection,    eiToneous,    defini- 
tion of.  113 
Prosopalgia.  130 
Pseudo-muscular  hypertrophy. 

270 
Psychiatry,  definition  of.  16 
Psychical  epilepsy,  404.  406 
Psychoses,  definition  of,  16 

sexual.  457 

traumatic.  400 


I 


INDEX. 


521 


Ptosis,  114 

morning  or  waking,  117 
Pupillary  skin  reflex,  30 
Purkinje  cells,  304 
Putamen,  298 

Rachischisis  posterior,  197 
Ranvier,  nodes  of,  5 
RaynaucFs  disease,  85 
Reaction  time,  14 
Reactions,    degenerative,     dis- 
eases in  which  they  may 
be  expected,  62 
degenerative,  testing  for,  GO 
Re-enforcement    of    the    knee 

jerk,  31,  32 
Reflex  action,  14,  20 

epileptiform     convulsions, 

404 
irritations,        neurasthenic 

form,  447 
pains  of  the  lumbar  nerves, 
172 
Reflexes,  20 
deep,  31 

examination  of  the,  29 
superficial,  29 
table  of  spinal-cord  levels 

for  the  superficial,  30 
tendon,  instrument  for  test- 
ing, 23 
Regeneration  of  nerves,  GS 
Representation,  bilateral,  318 
Retinal  hyperiesthesia.  111 
Rheostat,  55 
Roots,  spinal  nerve,  ISO,  186 

Sacral  nerves,  diseases  of  the, 

173 
Salaam  spasm,  151 
Saltatory  spasm,  433 
Sarcoma  of  the  brain,  391 
Scaphocephalie  skull,  27 
Scapular  reflex,  30 
Schmidt,  incisures  of,  6 
Schwann,  sheath  of,  5 


Sciatica,  174 
Scleroses,  44 

Sclerosis,  amyotrophic  lateral, 
265,  268 

disseminated,  374 

insular,  374 

multiple,  374 

multiple,  aborted  types  of, 
376 

multiple  cerebral,  376 

posterior  spinal,  231 

primary  lateral,  257 

spinal,  combined  with  soft- 
ening, 256 

spinal,  forms  of,  229,  248 
Scotoma,  definition  of,  108 
Secretion,  neuroses  of,  22 
Senile  chorea,  438 

paraplegia,  226 

vertigo,  143 
Sensation,  delayed,  21,  37 

double,  37 

examination  of  the  disor- 
ders of,  134 

transferred,  21 
Sense,  pain,  testing  the,  37 

pressure,  testing  the,  36 

tactile,  testing  the,  35 

temperature,  testing  the,  36 

weight,  testing  the,  38 
Sensibility,    muscular,    testing 

the,  37 
Sewing  spasm,  474 
Sex,  etiological  influences  of,  40 
Sexual  neurasthenia,  451 

neuroses  and  psychoses,  457 
Shingles,  170 
Shock,  etiological  influence  of, 

41 
Sick-headaehe,  125 
Side  pains,  163 
Singultus.  155 
Sinuses,  cerebral,  316 
Skin  reflex.  29 

Skull,  dimensions  and  shape  of, 
26 


522 


INDEX. 


Sleep,  accidents  of,  503 

disorders  of,  489 

normal,  490 

paroxysmal,  500 

perversions  of,  493 
Sleep-drunkenness,  495 
Sleeping  sickness,  503 
Smell,  disorders  of,  107 

instruments  for  testing,  145 

primary  centre  for,  320 
Smiths'  spasm,  474 
Softening  of  the  brain,  red,  349, 
362 

of  the  cord,  210 
Somnolence,  morbid,  500 
Spasm,  facial,  123 

flute-players',  474 

idiopathic  muscular,  29 

lingual,  147 

milkers',  475 

nodding,  151 

of  the  ocular  muscles,  120 

oscillating,  151 

salaam,  151 

saltatory,  433 

sewing,  474 

smiths',  474 

winking,  134 
Spasmodic  tic,  431 
Spasmus  nutans,  151 
Spastic  paraplegia,  249 

spinal  paralysis,  257 
Spermatorrhoea,  458 
Spina  bifida,  197 
Spinal  accessory  nerve,   anat- 
omy and    physiology  of 
the,  103 

accessory  nerve,  diseases 
of  the,  147,  148 

amyotrophy,     progressive, 
264 

anaemia,  204,  286 

apoplexy,  200 

concussion,  460 

cord,   amyotrophic    lateral 
sclerosis  of  the,  265,  268 


Spinal  cord,  anatomy  of  tlie,  180 

cord,  cavities  in  the,  280 

cord,    combined   sclerosis 

with  softening  of  the,  256 

cord,  hemorrhagic  cavities 

in  the,  280 
cord,  malformations  of  the, 

197 
cord,   myelitic    cavities    in 

the,  280 
cord,  physiology  of  the,  188 
cord,  i)rimary  lateral  scle- 
rosis of  the,  257 
cord,  relation  of  difierent 
parts  of  the,  to  the  per- 
ijDheral  nerves,  brain,  and 
each  other,  186 
cord,    secondary  degenera- 
tions of  the,  259 
cord,  syphilis  of  the,  398 
cord,  tumors  of  the,  277 
exhaustion,  288 
hypera^mia,  203,  286 
irritation,  286 
meningitis,  205 
nerves,  diseases  of  the,  153 
neurasthenia,  288 
paralysis,  spastic,  257 
Spotted  fever,  338 
Stabile  electrode,  58 
Stammering,  148 
Static  electrical  batteries,  55 
Status  epilepticus,  406 
Stellwag's  symptom  in  exoph- 
thalmic goitre,  464 
Stigmata,  24 

permanent,  of  hysteria,  419 
Stuttering,  148 
St.  Vitus'  dance,  436 
Substantia  nigra,  302 
Subthalamus,  302 
Suggestibility  in  hysteria,  425 
Sydenham's  chorea,  436 
Syncope,  laryngeal,  144 
Symptomatology    of     nervous 
diseases,  16 


INDEX. 


523 


Symptomatology  of  peripheral 

nervous  diseases,  178 
Syphilis,    hereditary,    nervous 
symptoms  of,  399 
of  the  nervous  system,  396 
Syphiloma  of  the  brain,  390 
Syringo-myelia,  281 

neuritic  type  of,  79 
Syringo-myelocele,  198 

Tabes  dorsalis,  231.     See  Loco- 
motor ataxia 

dorsalis,  pseudo-,  70 
Tachycardia    in  exophthalmic 

goitre,  463 
Tactile  sense,  testing  the,  35 
Tarsalgia,  88 
Taste,  disorders  of,  146 

instruments  for  testing,  145 

l^rimary  centre  for,  un- 
known, 320 
Telegraphers'  cramj),  474 
Temperature  sense,  testing  the, 

36 
Tendon  reflexes,  31 

reflexes,  instrument  for  test- 
ing, 233 
Tension,  definition  of,  53 
Tetanilla,  443 
Tetanus,  442 
Tetany,  443 
Thalami  optici,  299 

optici,   physiology  of  the, 
322 
Thermo-anaesthesia,    definition 

of,  20 
Thomsen's  disease,  433 
Thrombosis  of  the  brain,  362 
Tic,  convulsive,  18,  431 

coordine,  441 

de  pensee,  431 

douloureux,  130 

mimic,  132 

spasmodic,  431 
Tinnitus  aurium,  139 

cerebri,  139 


Tongue,    hemiatrophy  of  the, 
148 
paralysis  of  the,  148 
spasms  of  the,  147 
Topography,     cranio-cerebral, 

505 
Torticollis,  148 
Tracts,  cerebral,  306 

of  the  spinal  cord,  185 
Trance,  497 

Transferred   pains,   diagram 

showing  the  location  of,  82 

Trauma,   etiological    influence 

of,  41 
Tremor,  18 

convulsive,  432 
hysterical,  424 
testing  for,  28 
Trigeminus   nerve,    anatomy 
and  x3hysiology  of  the,  98 
nerve,  diseases  of  the,  120 
Trigonocephalic  skull,  27 
Trismus,  132,  442 
Trophic  disorders  in  hysteria, 

425 
Tropho-neuroses,  22,  484, 
Tubercula  dolorosa,  90 
Tubercular  meningitis,  340 
Tumors  of  nerves,  89 

of  the  base  of  the  brain,  389 

of  the  brain,  381 

of  the  central  region  of  the 

brain,  386 
of  the  cerebellum,  388 
of  the  corpora  quadrigem- 
ina,    deep    marrow,    and 
pineal  gland,  388 
of  the  corpus  callosum,  387 
of  the  crus,  338 
of  the   great  basal  ganglia 

and  the  capsule,  387 
of  the  occipital  lobes,  387 
of  the  parietal  area,  386 
of  the  pons  and   medulla, 

388 
of  the  iDrsefrontal  area,  385 


524  INDEX. 


Tumors  of  the  spinal  cord,  217 
of  the  temporal  area,  387 

Vagus  nerve,  anatomy  and 
physiology  of  the,  102 

nerve,  diseases  of  the,  147 
Vasomotor  symptoms,  23 

disorders,  484 
Veins  of  the  spinal  cord,  194 
Vertigo,  141 

arterio-sclerotic,  143 

auditory,  141 

bilious,  142 

laryngeal,  144 

lithsemic,  142 

mechanical,  143 

Meniere's,  141 

neurotic,  142 

ocular,  142 


Vertigo,  paralyzing,  144 

senile,  143 
Vicq  d'Azyr's  bundle,  306 
Tiolinists'  cramp,  474 
Vision,  primary  centre  for,  319 
Volt,  definition  of,  55 
Von  Graefe's  symjDtom  in  ex- 
ophthalmic goitre,  464 

Watchmakers'  cramp,  475 
Watt,  definition  of,  55 
Weight  sense,  testing  the,  38 
Word-blindness,  330 
Word-deafness,  331 
Wrist  drop,  164 
Wrist  reflex,  33 
Writers'  cramp,  468 
Wry-neck,  148 

ZoxES,  hysterogenic,  422 


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